OF  THL 

U N I VLRS  ITY 
or  ILLINOIS 

\'55. 


Digitized  by  the  Internet  Archive 
in  2016 


https  ://arch  ive  .org/detai  Is/textbookof  psych  iOObian 


• 


I 

I . 


I 


A TEXT-BOOK  OF  PSYCHIATRY 


A 


TEXT - BOOK 

OF 

PSYCHIATRY 

3for  pb^elcians  ant>  Stubents 


BY 

LEONARDO  BIANCHI,  M.D. 

Professor  of  Clinical  Psychiatry  and  Neuropathology  in  the  Royal  University  op 
Naples;  Minister  of  Public  Instruction  in  Italy;  Medical  Director  of  the 
Provincial  Asylum  of  Naples  ; Corresponding  Member  of  the  Medico- 
Psychological  Association  of  Great  Britain  and  Ireland,  etc. 


autbori3et)  translation  from  tbe  Italian 

BY 

JAMES  H.  MACDONALD,  M.B.,  Ch.B.  Glasg. 

Senior  Assistant-Physician  to  the  Govan  District  Asylum 


WITH  106  ILLUSTRATIONS 


WILLIAM 


NEW  YORK 

WOOD  & COMPANY 


MDCCCCVI 


■■  J 


PREFACE  TO  THE  ENGLISH  EDITION 

I HAVE  much  pleasure  in  presenting  to  English  readers  this  transla- 
tion of  Professor  Bianchi’s  ‘Trattato  di  Psichiatria,’  and  trust  that 
it  may  prove  a useful  addition  to  English  psychiatric  literature. 
Though  we  undoubtedly  possess  many  excellent  treatises,  still  it 
can  scarcely  be  denied  that  a number  of  these  are  defective,  because, 
dealing  chiefly  with  the  symptomatology  of  the  mental  affections 
and  but  slightly  with  cerebral  physiology  and  pathology,  they  are 
by  no  means  complete.  This  is  not  to  be  wondered  at  when  we 
remember  that  the  pathogenesis  of  insanity  has  all  along  been 
shrouded  in  mystery.  No  doubt  pathological  data  have  ever  been 
accumulating  both  at  home  and  abroad,  but  these,  like  stones  rough- 
hewn  from  a quarry  and  deposited  haphazard  with  no  attempt  at 
structural  design,  have,  from  their  isolation,  proved  of  little  service, 
even  whilst  by  no  means  wanting  in  intrinsic  worth.  Within  the  last 
decade,  however,  a 'real  advance  has  been  made.  The  histologist, 
the  morbid  anatomist,  the  pathological  chemist,  the  bacteriologist, 
the  biologist,  the  psychologist,  the  neurologist,  and  the  psychia- 
trist, working  patiently  each  in  his  own  particular  domain,  have 
awakened  to  the  fact  that  only  by  combined  effort,  by  the  co- 
operation of  the  various  branches,  is  true  progress  made  possible  , 
thus,  with  the  joining  of  forces,  a grand  architectural  edifice  is 
slowly  but  surely  being  erected  on  the  solid  foundations  of  physio- 
pathology.  To  this  end  no  country  has  contributed  more  largely 
than  Italy,  and  no  single  investigator  has  been  more  fruitful  than 
Professor  Bianchi. 

A treatise  from  the  pen  of  so  able  and  distinguished  an  observer 
as  the  author  of  this  work  must  command  the  attention  of  students 
of  psychiatry  everywhere.  Few  men  can  speak  with  greater 
authority  or  draw  from  a wider  experience  than  Professor  Bianchi, 
who,  as  Minister  of  Public  Instruction  in  Italy,  is  now  entrusted  with 
the  direction  of  the  educational  affairs  of  his  country. 

99?00 


vi  PREFACE  TO  THE  ENGLISH  EDITION 

In  giving  the  treatise  an  English  dress,  it  has  been  my  aim  to 
follow  as  closely  as  possible  the  original  text  and  to  act  as  a faithful 
interpreter  to  the  author. 

I acknowledge  with  gratitude  my  great  indebtedness  to  my 
friend  Dr.  J.  R.  Chalmers,  who  revised  almost  the  entire  MS.  I owe 
it  to  him  that  many  faults  have  been  eliminated  from  the  translation. 
My  thanks  are  also  due  to  my  colleague,  Dr.  Doig,  and  to  Drs.  Hunter 
and  Tierney  for  much  assistance  in  the  correction  and  revision  o 
proofs,  and  to  Mr.  John  Mactaggart,  who  was  a willing  amanuensis. 

J.  H.  MACDONALD. 


Govan  District  Asylum,  Hawkhead, 
October,  190  5- 


PREFACE  TO  THE  ITALIAN  EDITION 


Various  reasons  have  induced  me,  after  hesitating  long,  to  publish 
the  ‘ Treatise  on  Psychiatry  ’ which  I now  have  the  honour  of  pre- 
senting to  students^and  physicians.  Of  these  reasons,  one  of  the 
most  weighty  was  the  pressing  demand  for  a work  reflecting  the 
actual  state 'of  the  science,  and  that,  moreover,  an  Italian  work. 

I cherished  no  illusion  as  to  the  great  difficulties  involved  in  the  task. 
A text-book  which  aims  at  concentrating  what  is  most  important 
for  the  understanding  of  the  phenomena  of  psychic  life,  normal  and 
abnormal,  which  would  include  within  its  narrow  limits  what  is 
most  assured,  and  offer  ways  and  means  to  such  as  desire  guidance 
or  to  develop  in  various  directions  their  own  thoughts— such  a book 
cannot  pretend  to  make  use  of  all  the  rich  patrimony  of  accumulated 
literature  having  reference  to  psychopathology.  To  supply  the 
much-felt  want  of  a book  of  clinical  psychiatry  was  my  sole  object 
in  publishing  this  treatise.  My  work,  however,  would  not  be 
deserving  of  praise  had  I limited  myself  to  the  description  of  the 
nosographic  forms  and  varieties  of  the  mental  affections  and  to  the 

critical  examination  of  their  pathology. 

To-day,  in  Italy,  which  has  so  largely  contributed  to  the  progress 
of  the  physiology  and  histology  of  the  nerve-centres,  one  could  not 
understand  a book  on  psychiatry  unless  all  the  corollaries  drawn 
from  the  various  sources  were  utilized  in  the  interpretation  of  t le 
phenomena  of  psvchic  life.  The  physiology  of  the  brain,  on  the 
solid  foundations  of  morphology  and  histology,  constitutes  the  heart 
and  nutrient  vessels  of  a medical  work  on  psychiatry.  For  this 
reason  I have  deemed  it  useful  to  precede  the  description  of  the 
psychopathic  forms  with  a first  part,  which  summarizes  the  funda- 
mental laws  of  the  evolution  of  the  mind  in  relation  to  the  evolution 
of  the  nervous  system,  as  well  as  the  architectural,  anatomical,  an 
physiological  plan  of  the  human  brain,  particularly  in  relation  to 
mental  phenomena,  from  the  most  elementary  to  the  most  complex, 

vii 


PREFACE  TO  THE  ITALIAN  EDITION 


viii 

in  which  lies  the  synthesis  of  the  grandest  conquest  in  neurology  in 
the  last  quarter  of  the  past  century. 

Further,  the  consideration  that — unlike  the  student.of  the  present 
day,  who  is  taught  and  gains  experience  in  the  psychiatric  wards — 
the  physician  of  several  years’  standing  had  no  means.of  becoming 
acquainted  with  patients  suffering  from  mental  disorders,  and  is 
often  entirely  ignorant  of  psychiatry,  has  induced  me  to  follow  the 
first  with  a second  part,  which  is,  as  it  were,  an  introduction  to  the 
clinical  section,  being  devoted  to  the  semeiology  of  the  mental 
affections — that  is  to  say,  to  the  examination  of  the  elementary 
symptoms  of  the  disordered  mind,  and  to  the  analysis  of  their 
signification  in  relation  to  the  facts  of  normal  psychology,  and  to  the 
laws  which  govern  their  manifestation. 

The  physiological  conception  of  the  individual  psychopathies, 
and  the  description  of  the  nosographic  forms  which  these  assume, 
form  the  subject-matter  of  the  third  part,  naturally  more  voluminous 
than  either  of  the  other  two. 

To  simplify  matters  for  the  reader,  and  to  facilitate  the  under- 
standing of  the  clinical  forms  and  their  groupings,  was  the  chief  end 
I had  in  view.  If  I have  not  taken  the  reader  over  the  whole  of  the 
ground  covered  by  the  varieties  of  each  morbid  form,  it  is  because  I 
have  deemed  it  more  advantageous  not  to  let  him  lose  sight  of  their 
respective  synthetic  pictures. 

The  analytical  method,  though  useful  in  research  and  in  the 
monographic  treatment  of  single  subjects,  is  not  equally  so  in  the 
construction  of  a text-book,  the  tendency  of  which  must  be  towards 
synthesis  nourished  by  the  bulky  casuistic  production,  of  which  I 
have  sought  to  give  a sample  wherever  necessary,  so  as  to  give 
a better  concrete  form  to,  and  a clearer  impression  of,  the 
empirical  and  nosographic  conception  of  the  disease. 

Thus  it  happens  that  where  others  find  nosographic  differences, 
I have  been  led  rather  to  fuse  and  combine,  and  sometimes,  on  the 
other  hand,  to  draw  distinctions  between  clinical  forms  that  have 
been  confused  under  one  name.  This  has  not  come  from  any 
desire  for  originality,  but  as  the  logical  and  inevitable  consequence 
of  the  order  of  facts  observed. 

Whilst  the  attempts  to  break  down  the  old  walls  that  confined 
mental  pathology  have,  fortunately,  widened  immensely  the  domain 
of  the  latter,  they  have  sometimes  led  to  the  introduction  of  great 
confusion  in  the  nosographic  definition  of  the  disease,  a thorough 
knowledge  of  which  is  to  be  gained  only  by  long  observation  and 
the  prudence  that  comes  of  experience.  One  can  well  understand 
how,  in  the  series  of  observations  made  in  the  course  of  years, 
there  are  some  which  leave  a stronger  impression  than  others,  and 
invest  the  mind  of  the  pathologist  with  the  nosographic  synthesis  ; 


PREFACE  TO  THE  ITALIAN  EDITION 


IX 


on  the'other  hand,  the  individual  structure  stamps  on  the  mental 
affection— a fact  causing  it  to  differ  immensely  from  ordinary 
disease— particular  characteristics,  and  invests  it  with  appearances 
so  many  and  varied  that  the  observer  is  prone  to  deviate  from  the 
track  of  the  fimdamental  lines  that  serve  as  guides  to  the  nosographic 
diagnosis.  The  mental  disorder  issuing  from  the  darkest  depths  of 
the  mind  develops  in  divers  forms,  which  succeed  one  another  and 
are  variously  commingled  and  complicated.  It  is  in  the  midst  of  these, 
and  in  the  historical  process  of  their  development,  often  covering  a 
period  of  very  many  years,  that  we  may  retrace  the  conducting  lines 
of  the  clinical  synthesis. 

As  regards  pathological  anatomy,  aetiology,  and  therapy,  I have 
preferred  to  adhere  to  the  method  followed  in  general  medicine, 
although  this  method  involves  the  inconvenience  of  a certain 
amount  of  repetition.  We  must,  however,  recognise  that  it  has  this 
advantage,  that  we  have  under  our  eyes  the  pathological  conception 
of  each  nosographic  form,  with  all  the  differences  which  in  some  are 
even  conspicuous.  By  this  course  we  gain,  I think,  the  unison  of 
the  parts,  and  the  attention  of  the  reader  is  not  strained. 

I trust  that  this  work  will  meet  with  the  approval  of  physicians 
in  general  and  psychiatrists  in  particular  ; and  I feel  certain  that 
even  to  lawyers  and  magistrates  it  will  offer  a material  and  means 
for  a surer  and  clearer  vision  as  regards  the  new  horizon  of  the  law 
and  its  altogether  modern  application. 


PROFESSOR  L.  BIANCHI. 


CONTENTS 


CHAPTER 

INTRODUCTION 


PAGE 


I 


PART  I 

I.  ANATOMICAL  SKETCH  OF  THE  CEREBRAL  MANTLE  AND  OF  THE 

SUBMANTELLAR  WHITE  SUBSTANCE  - - - -24 

OLFACTORY  PATHS  AND  CENTRES  - - - - '3^ 

OPTIC  PATHS  AND  CENTRES  - - " " * 3^ 

ACOUSTIC  PATHS  AND  CENTRES  - - - ' “45 

PATHS  AND  CENTRES  OF  COMMON  SENSIBILITY  - - - 48 

MOTOR  PATHS  AND  CENTRES  - - - ' “59 

ASSOCIATIVE  PATHS  - - - ’ ' -7° 

MINUTE  ANATOMY  OF  CEREBRAL  CORTEX  - - - - 80 

II.  PHYSIOLOGY  OF  THE  CEREBRAL  MANTLE  - - - - 98 

LANGUAGE-  - - - - ' - 1 26 


PART  II 

I.  PHYSIO-PATHOLOGY  OF  PERCEPTION  - - - - 176 

II.  PHYSIO-PATHOLOGY  OF  ATTENTION  - - * - 224 

III.  PHYSIO-PATHOLOGY  OF  MEMORY  - - * - 239 

IV.  PHYSIO-PATHOLOGY  OF  IDEATION  - - - - - 29 1 

V.  PHYSIO-PATHOLOGY  OF  THE  EMOTIONS  AND  SENTIMENTS  - - 343 

X VI.  PHYSIO-PATHOLOGY  OF  THE  WILL  - - - " * 3^^ 

VII.  CONSCIOUSNESS  - - - ' ‘ ‘ ' 393 


PART  III 


I. /METHODS  AND  FIELD  OF  CLINICAL  INQUIRY  - - - 4OI 

II.  CLASSIFICATION  OF  THE  MENTAL  AFFECTIONS  - - - 416 


III. 

FIRST  GROUP — 

PHRENASTHENIAS  - 

- 

- 

- 

- 429 

IV. 

PARAPHRENIAS 

- 

- 

- 

- 470 

V, 

5 5 

DELINQUENCY 

- 

- 

- 

- 475 

VI. 

J5 

EPILEPTIC  INSANITY 

- 

- 

- 

- 503 

xi 


Xll 


CONTENTS 


I 

CHAPTER  i-AUC, 


VII. 

FIRST  GROUP — 

HYSTERICAL  INSANITY  - 

- 

- 

- 

533 

VIII. 

’j 

PARANOIA 

- 

- 

- 

570 

IX. 

5 » 

FIXED  IDEAS  AND  OBSESSIONS 

- 

- 

- 

620 

X. 

J5 

NEURASTHENIA  - 

- 

- 

- 

646 

XI. 

)5 

SEXUAL  PSYCHOPATHIES 

- 

- 

- 

660 

XII. 

SECOND  GROUP 

— GENERAL  CONSIDERATIONS 

- 

- 

- 

670 

XIII. 

MANIA 

- 

- 

- 

673 

XIV. 

MELANCHOLIA 

- 

- 

- 

685 

XV. 

J J 

MANIACAL-DEPRESSIVE  INSANITY 

- 

- 

701 

XVI. 

SENSORY  INSANITY 

- 

- 

- 

704 

XVII. 

JJ 

MENTAL  CONFUSION  - 

- 

- 

740 

XVIII. 

ACUTE  PARANOIA 

- 

- 

- 

742 

XIX. 

5 > 

LATE  PARANOIA 

- 

- 

- 

745 

XX. 

5 > 

NEURASTHENIC  INSANITY 

- 

- 

- 

747 

XXI. 

CHOREIC  INSANITY 

- 

- 

750 

XXII. 

5 J 

LUETIC  INSANITY 

- 

- 

753 

XXIII. 

5 > 

acute  DELIRIUM 

- 

- 

- 

755 

XXIV. 

JJ 

PELLAGROUS  INSANITY 

- 

- 

- 

760 

XXV. 

5J 

ALCOHOLIC  INSANITY  - 

- 

- 

- 

764 

XXVI. 

5J 

MORPHINIC  INSANITY - 

- 

- 

775 

XXVII. 

n 

COCAINIC  INSANITY  - 

- 

- 

- 

778 

XXVIII. 

> > 

CHLORALIC  INSANITY  - 

- 

- 

- 

780 

XXIX. 

5) 

SATURNINE  INSANITY  - 

- 

- 

- 

781 

APPENDIX — SECONDARY  DEMENTIA  - - - ■ 783 

XXX.  THIRD  GROUP — DEMENTIA  PARALYTICA  (PROGRESSIVE  PARALY- 


SIS,  GENERAL  PARALYSIS,  ETC.) 

- 

00 

00 

1 

XXXI. 

J) 

LUETIC  DEMENTIA 

- 

- 833  , 

XXXII. 

>3 

SENILE  DEMENTIA 

- 

- 838  1 

XXXIII. 

33 

POST-APOPLECTIC  DEMENTIA  - 

- 

1 00 
00 

XXXIV. 

33 

APHASIC  DEMENTIA 

- 

- 855 

XXXV. 

35 

TRAUMATIC  DEMENTIA  - 

- 870  ^ 

INDEX  OF 

AUTHORS 

- 

- 

- 879  i 

INDEX  OF 

SUBJECTS 

- 

- 

- 888  ■ 

/ 


LIST  OF  ILLUSTRATIONS 

PART  I 

PAGE 

Nervous  System  of  the  Medusa  - ...  y 

Nervous  System  of  the  Bee  - - - - - 7 

Nervous  System  of  Primary  Vertebrates  : Brain  of  Am- 

MOCCETES : Dorsal  Aspect  - - - - - 9 

Brain  of  Salmon  : Dorsal  Aspect  - - - . g 

External  Aspect  of  Cerebral  Hemisphere  - - - 26 

The  Insula  - - - - - - -27 

INTERNAL  Aspect  of  Cerebral  Hemisphere  - - - 29 

Inferior  Aspect  of  Cerebral  Hemisphere  - - ■ 31 

Scheme  of  Olfactory  Apparatus  in  Mammals  - - "33 

Another  Scheme  of  Olfactory  Apparatus  - - - 34 

Vertical  Section  of  Brain  at  Level  of  Anterior  Commissure  35 
Distribution  of  Fibres  of  Olfactory  Tract  - - - 37 

Scheme  of  Retinal  I.aa^ers  - - - - -38 

Course  of  Luminous  Rays  - . - - - - 39 

Course  of  Optic  Paths  from  the  Retina  to  the  Cortex  - 41 

Vialet’s  Scheme  of  Retinal  Projection  - - - 44 

Central  Course  of  the  Auditory  Fibres  - - - 46 

Another  Scheme  for  the  Auditory  Paths  - - - 47 

Course  of  Sensory  Fibres  in  Spinal  Medulla  - - 49 

Distribution  of  Fibres  of  Posterior  Root  in  Gray  Substance 

OF  Spinal  Medulla  - - - - - - 51 

Section  of  Medulla  Oblongata  at  Level  of  Decussation  of 
THE  Lemniscus  - - - - - - - 53 

Section  of  Medulla  Oblongata  in  Front  of  that  in  Fig.  21  - 54 

Course  of  Sensory  Fibres  to  the  Level  of  the  Anterior 
Corpus  Quadrigeminum  - - - - "55 

Topographical  Scheme  of  the  Cortical  Motor  and  Sensory 
Zones  --------  gi 

Course  of  the  Pyramidal  Pat  s - - - - 63 

Horizontal  Section  of  Left  Hemisphere  through  Basal 

Ganglia  and  Internal  Capsule  - - - - 64 

Scheme  of  Topographical  Distribution  of  Nerve  Bundles  in 

THE  Internal  Capsule  - - - - - - 66 

Network  of  Myelinated  Nerve  Fibres  in  Cerebral  Cortex  71 
Scheme  of  Chief  Associative  Bundles  - - - - 73 

Another  Scheme  of  Associative  Bundles  - - - 74 

xiii 


XIV 


LIST  OF  ILLUSTRATIONS 


PAGE 


31- 

32. 

33- 

34. 

35- 

36. 

37- 

38. 

39- 

40. 

41. 

42. 

43- 

44. 

45- 

46. 

47- 

48. 

49. 

50- 

51' 

52 

53 

54 


Vertical  Section  of  Cerebral  Hemisphere  of  Monkey  show- 
ing Degenerated  Associative  Bundles  : Weigert  s Method 
Vertical  Section  of  Cerebral  Hemisphere  of  Monkey,  show- 
ing Degenerated  Associative  Bundles:  Marchi  s Method - 
Vertical  Section  of  Human  Hemisphere  through  the 
Posterior  Parietal  Region  : Weigert’s  Method  - 
Vertical  Section  through  Posterior  Part  of  the  Insula, 
showing  Destructive  Focus  - - - “ ‘ 

Polymorphous  Cells  of  Molecular  Layer  of  Cortex 
Large  and  Medium-sized  Pyramidal  Cells 
Cells  of  External  Layers  of  Cortex 
Sensory  Corpuscles  of  Golgi  - - - ' 

Cells  with  Horizontal  Axon  in  Zone  of  Medium  and  Small 
Pyramids  of  Visual  Cortex  - - - ‘ " 

Cells  of  Internal  Layers  of  Cortex 
Cortex  of  Calcarine  Fissure  of  an  Adult  Brain  - 
’ Scheme  of  the  Nervous  Recticulum  from  Sensory  to  Motor 

Scheme  of  the  Tract  and  Connections  of  the  Neuro-fibrils 

IN  THE  Leech  - - " " ' 

Nerve  Cell  as  seen  by  Nissl’s  Method  - - 

: Scheme  indicating  Course  of  Sensory  Waves  for 

OF  Concrete  Visual  Images,  the  Higher  Mental  Products, 
and  ti  e Reflexes  of  Various  Grades 
Scheme  of  Mechanism  of  Language  in  tfe  Illiterate 
Another  Scheme  of  Language  in  the  Illiterate 
Scheme  of  Mechanism  of  Language  in  the  Educated  - 

Topography  of  the  Zone  of  Neuro-psychic  Factors  of 
Language 

Topography  of  Flechsig’s  Areas  of  Projection  and  Associa- 
tion : External  Aspect  - - “ v . 

Topography  of  Elechsig’s  Areas  of  Projection  and  Associa- 
tion : Inner  Aspect  - - ” 

Topography  of  Flechsig’s  Primordial,  Intermediate,  and 
Terminal  Territories  ; External  Aspect 
Topography  of  Flechsig’s  Primordial,  Intermediate,  and 
Terminal  Territories  : Inner  Aspect  - - 

Scheme  of  Psycho-physiological  Topography  of  the  External 
Aspect  of  the  Cerebral  Mantle 


PART  II 


55.  Scheme  indicating  Course  of  Sensory  Waves  For.l.tion  of 
Concrete  Visual  Images,  Higher  Mental  Produc  » * - ^ 
Reflexes  of  Various  Grades  - - ' _ 

^6.  Diagram  indicating  Mechanism  of  Illusions 
57.  ZOLLNER’S  Apparatus  for  Demonstrating  an  Illusion 
An  Illusion  of  Direction 

An  Illusion  of  Size  - - " “ 

ou.  Meningo-cerebral  Gumma 

61.  Diagram  indicating  Mechanism  of  Hallucinations 

62.  Diagram  indicating  Mechanism  of  Amnesia  - 


58. 

59- 

60. 


75 

76 

78 

79 

82 

83 

84 

85 

86 

87 

88 

92 

93 

94 


107 

139 

139 

140 

145 

150 

151 

154 

155 
174 


179 

200 

202 

203 
203 
219 
221 
268 


LIST  OF  ILLUSTRATIONS 


PART  III 


FIG. 

63.  Idiot  with  Infantile  Spastic  Hemiplegia 

64.  Another  Hemiplegic  Idiot  - - - - - 

65.  ^Iyxcedematous  Imbecile  _ _ _ _ _ 

66.  PORENCEPHALOUS  CEREBRUM  : EXTERNAL  ASPECT 

67.  PORENCEPHALOUS  CEREBRUM  : INTERNAL  ASPECT 

68.  Microcephalic  Idiot 

69.  Brain  of  INIicrocephalic  Idiot  ----- 

70.  Section  of  Cerebral  Cortex  of  Microcephalic  Idiot 
71-75.  Blood-pressure  Tracings  from  a Delinquent 

76.  A Katatonic  Stereotyped  Pose  in  a Hysterical  Subject 

77.  Specimen  OF  Writing  in  Hysterical  Insanity:  First  Stage 

OF  Improvement 

78.  Specimen  of  Writing  in  Hysterical  Insanity:  Advanced 

Stage  of  Improvement  _ _ _ - - 

79.  Specimen  of  Writing  after  Complete  Recovery  from 

Hysterical  Insanity  ------ 

80.  A Religious  Paranoiac  ------ 

81.  A Typical  Maniac 

82.  An  Agitated  MlELancholiac  _ _ _ - - 

83.  Scheme  of  Periodical  Mania  - _ - - - 

84.  Scheme  of  Periodical  Melancholia  _ - - - 

85.  86.  Scheme  of  Maniacal-depressive  Insanity 

87,  88.  Scheme  of  Mixp:d  Form  of  Periodical  Insanity  - 
89-91.  Schemes  of  Circular  Insanities  - - _ - 

92,  93.  Photographs  of  Patient  suffering  from  Hallucinatory 

CONFUSIONAL  INSANITY  ------ 

94.  Photograph  of  Patient  suffering  from  Sensory  Insanity  : 

Stupid  Form  ------- 

95.  Photograph  of  Patient  suffering  prom  Sensory  Insanity  : 

Katatonic  Form  __---- 

96.  Photograph  op"  Patient  suffering  from  Sensory  Insanity  : 

1 Paranoid  Form 

[ 97,  98.  Bacilli  p'ound  in  Blood  and  in  Cultures  from  Cases  of 
' Acute  Delirium  __---- 

99.  Xerve-cp:lls  of  Motor  Cortex  in  Dementia  Paralytica 
.00.  Nerve-cell  of  Motor  Cortex  in  Senile  Dementia  - 
01.  Nerve-cell  of  Anterior  Rolandic  Convolution  in  Senile 
Dementia  ------- 

^;o2.  Nerve-cell  of  Second  Frontal  Convolution  in  Senile 
I Dementia  ------- 

;03.  Nerve-cell  of  Second  Occipital  Convolution  in  Senile 
Dementia  ------- 

;04.  Nerve-cell  of  Anterior  Rolandic  Convolution  in  Senile 
Dementia  ------- 

f05.  Scheme  of  Mechanism  of  Language  in  Educated  Persons  - 
'06.  Topography  of  the  Zone  of  Neuro-psychic  Factors  op' 
Language  ------- 


XV 


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867 


ERRATA 


Page  48,  line  6,  for  ‘ crustaceans  ’ read  ‘ cetaceans.  ’ 

Page  139,  line  26,  for  ‘ expressive  ’ read  ‘ impressive.’ 

Page  310,  line  44,  for  ‘erotism  ’ read  ‘ eroticism.’ 

Page  523,  line  20,  for  ‘ carbonic  acid  ’ read  ‘ carbamic  acid.’ 


PSYCHIATRY 


INTRODUCTION 

Psychiatry  is  the  study  of  the  deviations  from  the  fundamental 
laws  of  the  formation  and  manifestation  of  mind,  and  the  various 
ways  in  which  these  deviations  are  displayed.  Briefly,  it  comprises 
the  study  of  mental  affections  in  their  widest  sense  ; but  as  time  and 
environment  give  rise  to  variations  in  the  contents  and  attitudes  of 
the  mind,  so  psychiatry  must  not  lose  sight,  inter  alia,  of  this  double 
source  of  numerous  and  various  factors  which  complete  and  consoli- 
date the  scientific  picture  of  this  branch  of  medicine. 

The  human  mind  is,  in  fact,  among  the  functions  of  the  organism, 
that  to  which  is  intrinsically  bound  the  conception  of  progress,  and 
which  embraces  all  the  laws  of  the  evolution  of  understanding  on 
the  one  hand,  and  of  the  brain  on  the  other.  We  can  readily  imagine 
as  rudimentary  the  mind  of  the  primitive  as  compared  with  that  of 
the  modern  evolved  races.  It  is  common  knowledge  that  the  mind 
of  modem  European  races  is  greatly  altered  as  regards  the  nature 
and  number  of  its  constituent  elements,  and  differs  from  that  of  the 
Hottentots,  the  Kaffirs,  the  negroes  of  Loango,  the  Redskins,  and  the 
Malays.  A rich  and  valuable  collection  of  anthropological  docu- 
ments affords  a proof  of  this  statement.  What  is  an  anomaly  or 
defect  in  individuals  of  a more  evolved  race  may  be  a normal  con- 
dition in  the  existence  of  other  people  who  have  not  reached  the  same 
grade  of  development,  or  in  whom  the  process  of  evolution,  operated 
on  by  the  most  diverse  circumstances,  has  branched  off  in  a different 
direction  and  with  a less  initial  velocity.  For  example,  to  the  in- 
stinct of  self-preservation  there  is  added,  among  some  people,  that 
of  a right  to  slay  and  spoil  ; the  chase  is  still  a custom  amongst 
people  advancing  towards  civilization,  but  in  the  most  advanced  it 
has  been  superseded  by  the  idea  of  displaying  personal  prowess  to 
the  advantage  of  the  individual  and  the  community,  thus  affording 
more  or  less  pleasure  to  one’s  self  and  others. 

Theft,  homicide,  want  of  chastity,  are  to  us  expressions  of  psychic 

I 


2 


PSYCHIATRY 


anomalies,  and  enter  into  the  domain  of  psychopathy  or  psycho- 
teratology, whilst  they  are  permitted  by  the  custom  obtaining 
among  other  peoples.  The  gradations  of  civilization  met  with  among 
the  various  races  of  to-day  can  be  retraced  in  the  history  of  each 
of  the  more  advanced.  The  early  Romans  abandoned  themselves 
as  a matter  of  course  to  theft,  slaughter,  plunder,  and  acts  of  rape. 
Later,  Rome  set  up  codes  which  regulated  and  directed  the  lives  of 
the  Roman  people  according  to  the  conceptions  of  private  and 
public  right,  and  these  codes  are  still  embodied  in  our  civil  legisla- 
tion. 

Such  a marvellous  development  of  the  thought,  sentiment,  and 
attitude  of  the  most  civilized  races  is  realized  by  a continuous  and 
incessant  arborization  of  the  components  of  the  human  understand- 
ing, which  year  by  year  is  further  perfected  by  the  action  of  all 
the  stimuli  from  without  which  Nature  is  incessantly  expending 
upon  the  nervous  system.  It  is  not  by  a process  of  stratification — 
a superimposing  upon  the  old  of  the  more  recent  products  of  the  mind 
which  alone  seem  to  animate  modern  life — that  such  a high  level 
of  development  has  been  attained. 

To  my  mind,  the  idea  of  germination  and  implantation  should  be 
considered  most  important.  On  the  original  wild  plant  there  is 
ingrafted  a bud  from  one  more  cultivated.  This  develops,  and  gives 
off  in  turn  branches  and  fruit  ; these  are  not  the  exclusive  product 
of  the  bud  grafted,  but  are  the  work  of  the  whole  plant,  which  fur-  , 
nishes  the  bud  with  nutritive  material ; and,  according  to  the  ' 
greater  or  less  receptivity  of  the  old  stem,  the  fruit  will  bear  some  of  , 
the  characters  of  the  wild  plant,  or  maintain  entirely  those  of  the  ; 
graft.  At  the  very  least,  however,  the  fruit  embodies  the  essential 
characteristics  of  the  latter,  which  has  sprouted  and  grown,  hyper-  , 
nourished  by  the  old  stalk,  and  the  seeds  contain  germinative  ; 
elements  which  for  the  most  part  repeat  the  characters  of  the  in-  ] 
grafted  bud.  If,  however,  this  latter  is  weak,  some  of  the  characters  ] 
of  the  old  plant  may  be  repeated.  So  it  is  with  the  human  mind.j 
Nature  is  its  vast  domain,  and  all  that  exists  therein  its  rightful^ 
patrimony.  ! 

Nature  is  continually  inserting  grafts  upon  the  old  branches  of 
the  human  understanding.  The  longer  the  action  of  its  forces  upon 
the  senses,  the  more  perfect  these  become,  and  the  progressive  adap- 
tation of  man  is  the  result  of  the  increased  receptive  and  assimilative 
power  exhibited  by  the  nervous  system  towards  the  forces  of 
Nature. 

This  potentiality  overcomes  the  law  of  habit,  which  would  tend 
to  fix  the  mechanism  in  the  senso-motor  adaptations  (^vide  L.  Dumont 
and  W.  James),  and  enlarges  the  mental  sphere  in  new  directions, 
so  that  there  is  a continual  sprouting  of  the  new  buds  ingrafted 
upon  the  great  intellectual  stem.  Thus,  human  thought,  from  the 
narrow  circle  of  the  individual,  widens  gradually  over  the  universe. 


INTRODUCTION 


* 3 

always  impressing  new  directions  upon  the  conduct,  along  unforeseen 
paths  of  progress.* 

One  of  the  fundamental  laws  of  psychic  being,  then,  is  that  of 
evolution,  emanating  from  two  co-ordinating  forces,  one  intrinsic 
in  the  primitive  organism,  the  other  extrinsic,  with  an  incessant 
tendency  to  break  through  the  habit  of  the  old  psychic  combinations, 
just  as  occurs  in  organic  life,  only  within  somewhat  narrower  limits. 
The  ovule  is  a cell  which,  by  virtue  of  its  inherent  property  and 
with  the  aid  of  material  accumulated  from  without,  divides  and  sub- 
divides itself  repeatedly  into  an  indefinite  number  of  other  cells, 
which  arrange  themselves  in  various  groups  and  dispositions, 
assuming  different  forms  and  functions.  With  the  division  coincide 
the  differentiation  and  grouping  of  the  cells  into  a progressively 
more  complex  and  harmonious  association. 

Such  a process  can  be  followed  both  in  the  individual  and  through- 
out the  entire  zoological  scale,  from  the  earliest  forms  of  life  to  the 
most  complex  development  in  man.  The  same  law  and  methods 
are  observed  throughout,  from  the  homogeneous  to  the  hetero- 

* It  may  happen  that  in  the  course  of  development  an  unhealthy  bud 
becomes  ingrafted,  or  that  the  new  buds  do  not  flourish,  or,  again,  that  agents 
within  or  without  operate  adversely  on  the  whole  plant  or  on  its  shoots. 
In  each  case  the  result  is  an  anomalous  product,  always  representing  either 
a deviation  from  the  law  of  development  or  a revival  of  primitive  character- 
istics, since  it  is  invariably  the  young  branches  that  are  the  more  markedly 
weak,  the  old  stem  remaining  more  or  less  unaltered. 

One  group  of  mental  affections  may  be  simply  indicated  thus — a revival 
of  the  primitive  characteristics  reminiscent  of  some  phase  through  which 
the  mind  of  the  individual  or  the  race  has  passed.  In  this  case,  owing  to 
intrinsic  conditions,  the  receptivity  shown  by  the  stem  to  the  graft  is  defec- 
tive ; in  other  words,  the  aptitude  to  assimilate  the  acquisitions  of  the 
collective  intellect  is  at  fault,  and  so  the  elements  of  the  original  mental 
organism  assume  greater  activity.  In  other  cases  the  ingrafted  buds  do  not 
fade  away  or  die,  but  give  forth  offshoots,  flowers,  and  bear  fruit.  The 
latter,  however,  present  some  characteristics  of  a former  graft,  once  normal, 
but  now  no  longer  in  harmony  with  the  new  qualities  assumed  by  the  plant. 
Another  group  of  mental  disorders  exactly  corresponds  to  this  conception — 
the  revival  of  some  of  the  characteristics  of  former  mental  acquisitions  or  of 
aptitudes  previously  laid  aside,  forming  new  psychic  combinations  in  which, 
naturally,  there  is  present  a certain  wealth  of  new  acquisitions. 

In  each  case  there  is  an  anomaly  of  individuality.  In  the  former  it  does 
not  attain  the  general  characteristics  of  the  entire  class,  and  arrest  takes 
place  (feeble  receptivity  for  grafts). 

In  the  second  category  it  is  different,  because,  at  a given  moment  of  its 
existence,  the  newly  assimilated  bud  has  not  a vigorous  growth,  owing  to 
defective  vegetative  power.  In  this  case  one  of  the  old  components  of  the 
individual  or  collective  mind  sprouts  up  and  gives  a new  imprint  and  a new 
direction  to  all  the  extrinsic  characteristics  of  the  psycho-organic  unit  which  we 
term  personality.  If  the  personality  can  undergo  such  a profound  alteration 
through  deviations  from  the  law  of  receptivity  or  of  development,  it  is  not, 
however,  the  only  manner  in  which  it  transforms  itself,  because  the  preserva- 
tion of  the  personal  type  depends  also  on  the  intrinsic  conditions  governing 
the  reciprocal  position  and  relations  of  the  formative  elements  of  the 
mind. 


I — 2 


4 


PSYCHIATRY 


geneous,  the  simple  to  the  complex,  the  inco-ordinate  to  the  co- 
ordinate, and  from  the  independent  to  the  associated,  thus  securing 
solidity  and  functional  harmony  to  the  diverse  parts  of  the  organism. 
What  is  found  in  the  development  of  the  somatic  organism  is 
present  also  (and  that  without  substantial  difference)  in  the  evolu- 
tion of  the  psychic  organism,  or  mind.  This  law  thus  becomes  the 
universal  law  of  life.  Life,  which  from  monad  to  man  is  essentially 
the  same,  is  only  a dynamism,  of  which  intelligence  is  merely  the  sub- 
jective side  (Soury).  Further,  life  is  a phenomenon  ; it  is  the  most 
delicate  dynamism  in  the  universe,  and  is  prevalent  in  all  Nature. 
Intelligence  is  the  consciousness  of  life,  and  is  manifested  through 
the  wonderful  mechanism  of  the  nervous  system,  its  grade  and  de- 
velopment corresponding  to  the  development  of  this  system  and  the 
associative  capacity  of  its  parts. 

Psychic  life  commences  with  very  simple  and  uncertain  mani- 
festations, and,  step  by  step,  through  progressive  assimilation  of 
the  forces  of  Nature,  it  rises  to  the  most  potent  realization  of  Nature 
itself  in  the  form  of  thought  and  consciousness. 

Occasionally  there  come  under  our  observation  phenomena  which 
appear  to  simulate  those  of  the  period  of  transition  between  the 
manifestations  of  the  brute  energies  and  of  intelligence.  It  is 
impossible,  however,  to  assign  extent  and  precise  limits  to  the  con- 
ception of  intelligence,  nor  are  all  agreed  on  this  point.  If  by  in- 
telligence we  understand  the  transformation  of  the  energies  of 
external  nature  into  another  energy  in  the  protoplasm,  and  the 
reaction  of  the  latter  on  the  former,  we  can  then  also  attribute  to 
the  most  elementary  forms  of  life  and  to  the  elements  from  which  they 
emanate  (plastiduli)  the  quality  of  intelligence.  But  if  by  intelli- 
gence we  understand,  not  only  the  transformation  of  the  cosmic 
energies  in  the  dynamism  of  the  cell — in  the  chemical  molecular 
compound,  as  Danilewsky  calls  it — but  also  the  consciousness  of 
them,  and  the  conscious  reaction  of  the  organism  upon  its  environ- 
ment, we  must  refuse  to  consider  as  intelligent  the  plastiduli,  the 
protoplasm  of  the  earliest  representatives  of  life,  besides  the  amoeba, 
rhizopods,  infusoria,  and  all  the  protophyta  and  protozoa. 

Let  us  here  understand  clearly  that  doctrines  which  partake  of 
the  metaphysical,  even  boasting  their  origin  from  positivism,  such 
as  that  which  discusses  the  universal  intelligence  of  matter,  are 
entirely  beyond  the  scope  of  this  book.* 

* The  question  of  the  earliest  manifestation  of  intelligence,  exhibited  in 
its  true  limits  and  with  great  lucidity  by  Soury  {Revue  gen^ale  des  Science^} 
pures  et  appliquees,  1895),  has  been  taken  up  again  recently  by  P.  Heger, 
of  the  University  of  Brussels.  According  to  him,  the  solution  of  the  psycho- 
logical problem  is  not  at  all  to  be  found  in  the  brain,  but  should  be  sought  for 
in  the  study  of  the  structure  and  reactions  of  protoplasm.  Thought  is  a 
primitive  and  essential  manifestation  of  protoplasmic  activity.  To  him, 
as  a convinced  monist,  the  brain,  so  far  as  thought  is  concerned,  if  taken  into 
account  at  all,  is  merely  accessory.  It  is  not  the  generative  organ  of  thought. 


INTRODUCTION 


5 


If,  under  certain  stimuli,  the  protoplasm  of  the  amoeba  moves 
in  diverse  directions,  thrusting  out  its  pseudopodia  or  withdrawing 
them  ; if  it  arrests  its  progress  on  finding  itself  confronted  by  a 
stronger  micro-organism  ; if  it  awaits  the  rupture  of  the  sac  of  a 
pregnant  mother  in  order  to  attack  the  young  prey  (Romanes)  ; if 
some  infusorians  seek  the  light  and  others  avoid  it  ; if  decapitated 
worms  present  certain  particular  attitudes  under  the  action  of  light 
'and  of  single  luminous  rays,  as  Graber  has  observed,  one  cannot 
therefore  conclude  that  these  beings  have  perceived  and  reacted  in 
consequence.  Max  Verworn  has  expressed  an  opinion  that  many 
sensations  of  the  vertebrates,  such  as  hearing  in  air,  do  not  exist  in 
the  protozoa.  What  falsely  appears  to  be  a sensation  can  easily 
be  shown  to  be  the  effect  of  physico-chemical  changes.  If  amoebae 
seem  sensible  to  noises,  one  cannot  on  that  account  conclude  that 
they  perceive  the  sonorous  waves.  One  can  reasonably  contend 
that  the  mechanical  vibrations  of  the  air  have  changed  the  existing 
conditions  of  their  protoplasm.  If  some  protozoans  are  capable  of 
distinguishing  differences  in  intensity  of  light  or  colour  (by  the  length 
of  the  luminous  waves),  no  one  can  assert  that  these  differences  are 
i properly  perceived  as  such,  and  that  the  luminous  body  is  recognised 
in  the  surroundings  and  at  some  distance. 

If  the  red,  violet,  or  orange  rays  modify  the  rapidity  and  direction 
of  the  movements  of  some  bacteria,  one  cannot  deny  that  these 
manifestations  are  due  first  to  physico-chemical  actions,  and  then 
to  the  capacity  of  adaptation  of  the  protoplasm  to  certain  conditions 
of  existence.  It  is  very  probable,  then,  that  the  locomotor  reactions 
i observed  in  the  protozoa,  protophyta,  and  some  invertebrates 
I depend  less  on  the  existence  of  true  luminous  or  chromatic  sensa- 
I tions  than  on  the  thermal  or  chemical  effects  of  the  luminous  waves, 
i Forel,  Max  Verworn,  and  Soury  have  expressed  such  an  opinion  ; 

I the  photodermic  or  dermoptic  sensations,  as  Graber  calls  them,  and 
phototropic  phenomena  in  general,  have  nothing  in  common  with  the 
perception  of  objects  and  colours,  just  as  the  dermo-mechanic 
sensations  of  aerial  vibrations  and  heliotropic  phenomena  have 
nothing  in  common  with  the  perception  of  sounds  and  noises  or  of 
the  bodies  which  produce  them.  Yet,  on  the  other  hand,  they  repre- 
sent  something  absolutely  new  in  the  manifestations  of  organized 
matter — a phase  of  evolution  preparing  for  perception,  which  makes 
its  appearance  along  with  the  more  advanced  differentiation  of  the 
protoplasm.  From  manifestations  characterized  by  nictitropic  and 
heliotropic  movements  life  advances,  and  is  exhibited  in  another 
category  of  movements  arising  from  needful  variations,  repeated 
j according  to  habit,  fixed  by  heredity,  and  reinforced  by  selection 

, though  the  organ  indispensable  for  the  exercise  of  the  mental  faculties.  Put 
in  this  way,  the  question  exceeds  the  confines  of  positive  psychology  and 
physiology,  and  enters  at  a bound,  perhaps  without  the  intention  of  the 
1 authorities  concerned,  the  realm  of  metaphysics. 


6 


PSYCHIATRY 


(Darwin).  These  movements,  however,  represent  a much  higher  . 
step  in  the  ladder  leading  to  intelligence  in  higher  beings.  They 
represent  phases  of  transition  in  the  evolutionary  stages  of  Nature, 
which  tends  to  form  for  itself  an  organ  which  attends  to  it  and  sums 
it  up.  Here  we  have  a surprising  phenomenon — the  slow  trans- 
formation of  the  physical  forces  into  those  of  the  protoplasm,  and 
the  successive  transformation  of  the  latter,  according  to  the  various 
dynamic  agents  of  the  universe. 

When  the  nervous  tissue  becomes  differentiated  from  the  others 
and  develops  with  particular  characteristics,  the  relations  of  the 
organism  to  the  cosmic  agents  become  multiplied,  the  receptive  and 
metabolic  power  of  the  former  with  respect  to  the  latter  increases, 
and  hence  the  result  is  new  adaptations  and  unexpected  reactions, 
which,  further,  are  always  more  complicated. 

Electricity,  heat,  light,  etc.,  all  manifestations  of  organic  and  in- 
organic matter  in  various  contingencies  or  particular  combinations, 
are  summed  up  in  the  nervous  system,  which,  therefore,  must 
realize  the  combinations  and  contingencies  which,  with  the  same 
laws,  contribute  to  the  manifestation  of  these  energies.  The  firefly, 
which,  by  rhythmic  nervous  discharges,  sheds  its  starry  light  on  the 
green  held,  as  though  envious  of  the  Armament ; the  gymnotus, 
which  kills  its  prey  or  paralyzes  its  enemy  with  an  electric  shock, 
volitional  in  the  same  manner  as  the  molecular  force  displayed  by  all 
beings  furnished  with  a nervous  system  and  muscles,  are  manifesta- 
tions  of  the  most  marvellous  phenomena  by  which  the  universe  ; 
obtrudes  itself  upon  us.  A muscular  contraction  with  its  dynamic 
effects — kilogrammes  or  calories — its  milliamperes  of  electricity,  its  ^ 
chemical  changes  in  the  muscle,  the  distribution  of  homologous  and  ' 
antagonistic  forces  whose  resultant  impresses  a definite  direction 
upon  the  movement — all  these  involve  many  principles  of  mechanics,  i 
and  briefly  comprise  a volume  of  chemistry  and  physics.  The  dis-  ; 
charge  of  light,  electricity,  or  mechanical  force  is  always  due  to  the  ( 
transformation  of  the  nervous  wave  accumulated  in  the  nervous  | 
tissue,  which,  consequently,  is  to  be  regarded  as  the  synthesis  of ; 
matter  and  its  forces,  inasmuch  as  the  nervous  system  changes  the  ^ 
cosmic  energies  into  psychic  equivalents.  i 

The  homogeneity  of  some  of  the  first  representatives  of  animal] 
life,  such  as  the  primitive  protamoebse,  in  which  the  same  substance,' 
performs  digestion,  assimilation,  excretion,  respiration,  sensation, 
and  movement  ; the  slow  differentiation  of  the  protoplasm  in  the  j 
rhizopods  and  infusorians  ; the  appearance  of  the  first  muscular  fibre  | 
by  progressive  differentiation  of  the  protoplasm  in  Noctilucus  miliar,  | 
and  of  probably  the  first  nerve  fibre  in  ScylonicJna  mytilus  (Engel- 1 
mann)  ; the  undoubted  appearance  of  the  nerve  cell  in  the  actinians 
and  the  progressive  development  of  the  nervous  system  up  to  that 
of  man,  warrant  the  legitimate  deduction  that  from  simple  matter 
the  nerve  cell  becomes  differentiated  by  its  own  intrinsic  energy,  and 


INTRODUCTION 


7 


that  Nature,  exerting  its  influence  upon  the  cell,  may  create  the 
means  of  attaining  to  the  consciousness  of  itself. 

From  the  first  appearance,  however,  of  the  nervous  system  to 
its  highest  degree  of  development  there  is  only  a numerical,  almost 
continuous,  increase  of  nervous  elements,  with  a proportionate 
development  of  the  consciousness  of  Nature  and  of  the  relative 
adaptations  of  the  organism  towards  its  environment. 

The  developmental  plan  of  the  nervous  system  is  the  same'"as 
that  regulating  the  evolution  of  life.  At  first  it  is  only  some  few 
nerve  cells  which  provide  for  the  function  of  all  parts  of  the  small 
organism  ; then  more  cells,  or  little  groups  of  cells  more  or  less 
regularly  disposed  and  almost  independent  of  each  other,  look  after 


Fig.  I. — Nervous  System  of  the 
Medusa:  Scattered  Nerve  Cells 

FORMING  THE  SUPERIOR  RiNG. 

(After  Oscar  and  Richard  Hert- 

WIG.) 


Fig.  2. — Nervous  System  of  the 
Bee.  (After  Blanchard  and 
Beaunis.) 


separate  parts  of  the  now  larger  organism,  which  thus  becomes  less 
homogeneous,  as  seen  in  the  medusae,  which  are  already  provided 
with  a sensitive  ectoderm  innervated  by  a specialized  nervous 
reticulum  (Fig.  i). 

The  nervous  system,  from  the  medusae  and  echinoderms  to  the 
higher  insects — e.g.,  ants  and  bees — follows  a slow  but  progressive 
evolution. 

In  the  latter,  as  compared  with  worms,  crustaceans,  and  arach- 
noids, we  find  a great  increase  in  the  mass  of  nervous  tissue,  a greater 
concentration  and  solidity,  besides  a more  distinct  differentiation  of 
the  groups  of  cells,  along  with  a higher  functional  grade  of  these, 
so  that  we  are  now  able  to  speak  of  a central  lobe,  an  antennar  lobe, 
an  optic  lobe,  pedunculate  bodies,  etc. 


8 


PSYCHIATRY 


There  is  here  diagrammatically  represented  the  nervous  system 
of  a bee.  In  this  figure  we  can  observe  the  antennar  lobes  (tactile, 
olfactory,  and  perhaps  auditory  in  function),  the  optic  lobes  situated 
laterally,  and  the  pedunculate  bodies,  which  by  some — e.g.,  Dujardin 
— have  been  considered  (on  doubtful  grounds)  the  first  indications  of 
the  convolutions.  In  the  vertebrates  the  fusion  and  concentration 
of  the  nervous  system  are  remarkable.  The  two  chains  of  separate 
ganglia  which  are  met  with  in  the  annelides  and  the  worms  are  here 
fused  into  the  spinal  cord,  and  the  antennar,  optic,  supra-  and  sub- 
oesophageal  ganglia,  etc.,  are,  as  we  ascend  in  the  scale,  increasingly 
collected  together  into  one  single  mass — the  cerebrum — so  as  to 
establish  more  intimate  associative  relations  with  each  other  ; but 
how  greatly  does  this  cerebrum  still  differ  from  that  of  the  mammals  ! 

The  cerebrum  of  the  vertebrates  presents  a new  formation — the 
anterior  brain — whose  cavity  communicates  with  that  of  the  olfac- 
tory lobe  (antennar  lobe  of  the  invertebrates)  in  the  fishes,  whose 
first  representatives  are  furnished  with  a cerebral  mantle.  This 
mantle  is  merely  a thin  layer  composed  of  cells  bearing  a strong 
resemblance  to  epithelial  cells  (some  cyclostomata),  or  containing 
only  the  first  hippocampal  formations  (myxine). 

The  mantle  goes  on  developing  and  increasing  in  nerve  elements 
in  the  different  classes  of  the  vertebrates  till  it  reaches  the  surprising 
development  seen  in  the  higher  mammals,  in  which  we  find  it  more 
or  less  superimposed  on  the  representatives  of  the  old  ganglia — the 
only  nerve  centres  of  the  higher  invertebrates. 

The  development  and  differentiation  of  the  cerebral  mantle 
proceed  almost  uniformly,  while,  at  the  same  time,  the  parts  com- 
posing it  assume  closer  relations  and  greater  functional  eminence 
according  as  we  advance  from  the  fish  to  the  higher  mammals, 
reaching  the  highest  grade  in  man.  In  like  manner  we  find  that  man 
himself,  in  continuing  the  story  of  the  development  of  the  nervous 
system,  can  add  to  the  marvellous  phenomena  seen  in  the  progressive 
increase,  the  concentration,  the  anatomical  and  functional  differ- 
entiation, the  closer  association  between  parts,  and  the  development 
of  new  formations,  such  as  the  cerebral  mantle  of  the  mammals 
as  compared  with  the  condition  found  in  the  inferior  vertebrates 
(cerebral  mantle  absent),  and  the  frontal  lobes  of  man  as  compared 
with  the  brain  of  the  inferior  mammals. 

We  may  infer,  among  other  things,  that  these  parts,  being  latest 
in  appearance,  sum  up,  in  a higher  order,  the  activity  of  the  nervous 
system  up  to  that  time  existent,  and  regulate  themselves  according 
to  the  supreme  law  of  the  division  of  labour,  or  distribution  of  offices, 
and  exercise  a regulating  and  directing  influence  on  their  har- 
monious working. 

It  is  observed  as  an  almost  constant  feature  that  with  the 
increase  of  the  nerve  elements  occurs  a better  assimilation  of  those 
influences  from  the  outer  world  which  we  are  accustomed  to  call 


INTRODUCTION 


9 


stimuli.  These  influences  or  stimuli  impress  on  the  nervous  elements 
that  functional  differentiation  to  which  is  due  the  multiplication  of 
ideas  and  adaptations  by  which  Nature,  through  the  medium  of  the 
nervous  system,  becomes  known  to  itself. 

The  experimental  method,  extensively  but  rigorously  applied, 
surprising  the  developing  nervous  system  in  all  the  stages  passed 
through  in  the  animal  series  (phylogenesis)  and  in  the  individual 
(ontogenesis),  permits  the  assertion  that  the  mind  is  coextensive 


Pjq_  2. — Nervous  SystExV  of  the 
Primary  Vertebrates  ; Brain 
OF  Ammoccetes  seen  from  the 
Dorsal  Aspect. 

c a,  Anterior  brain ; lol,  olfac- 
tory lobe;  o,  olfactory  nerve  ; ci, 
intermediate  brain  ; g p,  pineal 
gland  ; c m,  mid  brain  ; c p,  pos- 
terior brain  ; n ti,  after  brain  ; 
m s,  spinal  medulla.  (From 
Wiedersheim. ) 


Fig.  4. — Brain  of  Salmon  seen  from 
Dorsal  Aspect. 

o.  The  so-called  olfactory  nerve ; lol, 
olfactory  lobe  ; pal,  pallium  ; g b,  gang- 
lion of  the  base  of  the  anterior  brain  ; 
c a,  anterior  brain  ; c m,  mid  brain  ; g p, 
pineal  gland  ; c p,  posterior  brain  ; m s, 
spinal  medulla.  (From  Wiedersheim.) 


with  the  nervous  elements,  or,  in  other  words,  with  the  number  of 
notions  and  adequate  adaptations. 

Psychopathology,  pursuing  similar  objects  and  proceeding  back- 
ward in  the  process  of  mental  analysis  through  all  the  regressive 
phases  to  its  simplest  formula,  has  succeeded  in  analyzing  the  human 
understanding  and  that  of  the  inferior  beings,  and  in  separating  one 
by  one  the  elements  of  which  it  is  composed.  It  is  by  this  pro- 
gressive mode  of  analysis  of  mind,  individual  as  well  as  racial,  that 
success  in  following  up  the  evidence  of  the  evolutionary  process  has 
been  obtained.  Both  methods,  now  regarded  as  sure  and  produc- 


10 


PSYCHIATRY 


tive  branches  of  the  science,  have  furnished  us,  in  the  first  place, 
with  the  key  whereby  we  arrive  at  the  beginning  of  the  architectural 
and  functional  plan  of  the  brain  of  modern  man,  and,  secondly,  with 
some  laws  by  which  this  marvellous  structure,  upon  which  Nature, 
from  time  immemorial,  has  been  at  work,  in  order  that  it  may  rule 
the  vast  dominions  belonging  to  her,  is  completed  and  perfected. 

The  story  of  the  evolution  of  the  nervous  system,  whether  con- 
sidered in  the  perfect  organism  or  constructed  on  the  story  of  the 
development  of  the  brain,  is  summarized  under  the  following 
headings,  which  are  the  sure  foundation  of  the  anatomo-physiological 
structure  : 

1.  The  progressive  increase  of  the  nerve  elements. 

2.  The  progressive  histological  and  functional  specific  differen- 
tiation. 

3.  The  intervention  of  a continually  increasing  number  of  nerve 
elements  in  the  work  of  the  community,  in  order  to  furnish  products 
more  complex  and  more  useful  for  the  increase  of  the  consciousness. 

4.  The  closer  association  between  the  increasing  number  of  nerve 
elements  the  higher  the  degree  of  function  to  be  performed. 

5.  The  formation  of  functional  hierarchies  in  accordance  with  the 
law  of  the  greater  aptitude  for  the  government  of  other  functions. 

6.  The  reservation  of  all  the  products  of  the  cerebral  offices  in  the 
great  storehouses  of  the  organic  memory  which  furnish,  with  or 
without  the  knowledge  of  the  subject,  the  measure  of  the  present- 
day  mind  and  the  tone  of  the  character. 

7.  The  complete  observance  of  the  laws  of  organic  life,  besides 
time  and  space — that  is  to  say,  of  the  laws  of  the  universe. 


I.  The  Progressive  Inerease  of  the  Nerve  Elements. 

On  this  point  I have  said  all  that  is  required.  Only,  to  complete 
the  proof  so  far  as  concerns  the  brain  of  the  higher  mammals  and  ; 
that  of  man,  I would  add  that  the  researches  of  Broca,  Reid,  Peacock,  i 
Bischoff,  Calori,  Weissbach,  and  many  others,  at  home  and  abroad,  ; 
have  clearly  shown  that  the  weight  of  the  human  brain  among 
modern  Europeans  oscillates  between  1,417  and  1,272  grammes,, 
which  figures  prove  that  it  is  superior  in  weight  to  that  of  the  majority 
of  living  things* — that  is,  in  relation  to  the  weight  of  the  body — so 
that  while  the  elephant’s  brain  reaches  a weight  of  4,166  to  4,770 
grammes,  the  bull’s  400  to  700  grammes,  the  gorilla’s  567  grammes, 

* Donaldson,  in  an  important  publication  (‘  The  Growth  of  the  Brain,’ 
New  York,  1895)  raises  the  mean  weight  of  the  brain  to  1,360  grammes  in  | 
adult  individuals  of  twenty  to  forty  years,  and  of  a height  of  1*67  to  1-72  | 
metres.  These,  naturally,  are  mean  figures.  i 

1 1 is  well  to  bear  in  mind  that  there  is  a great  individual  variety,  not  easy 
of  explanation,  recollecting  that  the  brain  of  Gambetta  weighed  1,000 
grammes,  that  of  Turghenieff,  on  the  other  hand,  2,012,  while  it  is  no  rare 
thing  to  find  ordinary  workmen  with  a brain  weighing  2,000  grammes.  I 


INTRODUCTION 


II 


the  whale’s  3,000  grammes,  still,  the  proportion  of  brain  to  body- 
weight  in  the  young  elephant  is  1:500,  in  the  ox  from  i : 500  to 
I : 800,  and  in  the  adult  gorilla  i : 100,  while  in  man  it  is  1-36  : 58. 

On  the  other  hand,  it  is  known  that  the  brain  weight  of  Euro- 
peans exceeds  that  of  the  African  negroes  by  12  per  cent.  (Broca), 
and  by  even  more  that  of  the  aboriginal  Australians  and  Bushmen. 

The  increase  occurs  in  greater  proportion  in  those  parts  of  the 
brain  which  are  latest  in  appearance— that  is,  in  the  cerebral  mantle, 
which,  little  by  little,  assumes  an  enormous  size  and  weight  in  com- 
parison with  the  posterior  and  after  brains,  relatively  much  more 
developed  than  the  hemispheres  in  the  inferior  vertebrates.  It  is 
sufficient  to  give  here  one  example.  The  hemispheres,  which  in 
some  of  the  lowest  vertebrates  are  composed  of  a simple  thin  mem- 
brane, reach  in  man  1,157  grammes,  while  the  cerebellum  weighs 
142  grammes  and  the  medulla  oblongata  hardly  26-5  grammes. 

On  the  other  hand,  the  number  of  nervous  elements  increases  in 
an  extraordinary  manner,  seeing  that  the  gray  substance  of  the 
human  hemisphere  is  not  only  much  thicker  than  in  other  brains, 
but  is  also  beyond  comparison  more  extensive,  by  the  formation  of 
folds  and  sulci  of  a notable  depth. 

With  the  attainment  of  the  gray  substance  of  the  cerebral  mantle 
to  such  extraordinary  proportions,  the  number  of  cells,  according  to 
Meynert,  rises  to  as  many  as  612,000,000  ; according  to  Donaldson, 
with  approximate  calculations,  to  1,200,000,000  ; and  according  to 
Hammarberg*  to  9,200,000,000.  Their  diverse  forms  and  dispositions 
give  us  good  reason  to  suspect  that  their  physiological  mechanism 
and  their  functional  attributes  may  equally  vary,  and  that  they  offer, 
therefore,  conditions  most  favourable  for  development  in  this  new 
sphere,  possessing  still  unexplored  divisions  of  the  great  intellectual 
tree,  nourished  by  all  the  forces  of  Nature. 

2.  Progressive  Specific  Differentiation  front  the  General  to  the  Par- 

ticular, from  the  Simple  to  the  Complex. 

3.  Intervention  of  an  always  increasing  Number  of  Nerve  Elements 

in  the  Work  of  the  Community,  in  Order  to  furnish  Products  more 
Complex  and  more  Useful  for  the  Increase  of  the  Consciousness. 

To  demonstrate  these  two  propositions,  I shall  have  recourse  to 
two  examples — one  from  Huxley,  which  will  render  more  apparent 
the  objective  truth  contained  in  them. 

The  savage  who,  confronted  by  an  enemy,  uses  a club  for  self- 
defence,  and  a fencing-master  in  modern  civil  society  who,  in 
identical  conditions,  uses  the  sword,  both  bring  into  action  for  the 
same  object  the  same  muscles  of  the  upper  limb. 

While,  however,  the  savage  executes  coarse  movements,  making 

* ‘ Studien  iiber  Klinik  und  Pathologie  der  Idiotic  ncbst  Untersuchungen 
liber  die  normale  Anat.  der  Hirnrinde.’  Upsala,  1895. 


12 


PSYCHIATRY 


a useless  expenditure  of  his  energy,  the  fencing-master,  more  com- 
posed, performs  a series  of  very  delicate  movements,  each  having 
its  proper  why  and  wherefore,  and  all  co-ordinated  with  precise 
judgment,  and  in  wonderful  harmony  with  the  two  objects  of  attack 
and  defence.  Again,  the  savage,  not  knowing  how,  cannot  employ 
other  more  adequate  movements  for  the  attainment  of  the  object 
which  he  has  in  view,  while  the  fencing-master  can  perform  in  addi- 
tion those  of  the  savage,  the  aimlessness  and  inferiority  of  which, 
however,  he  recognises. 

In  the  fencing-master  a functional  differentiation  has  occurred 
in  the  motor  cells  of  the  cortex  of  the  right  upper  limb,  and  new 
associations  have  been  formed  by  the  intervention  of  cells  which 
perhaps  have  till  now  remained  inactive,  the  result  being  a more 
complex  and  better  co-ordinated  product. 

Suppose  now  that  the  fencing-master  lays  down  the  sword  and 
takes  up  the  pen  to  describe  his  thrusts  and  parries.  It  is  easy  to 
understand  that  a marvellous  development  must  have  been  achieved 
by  his  brain  and  that  a more  delicate  co-ordination,  based  upon  new 
and  more  complex  associations,  must  have  been  rendered  possible 
to  the  same  muscles  in  him  as  were  employed  by  the  savage,  so  as 
to  enable  the  fencing-master  to  put  down  on  paper  the  graphic 
symbols  of  the  movements  executed  by  him,  and  of  all  the  exciting 
episodes  of  the  assaults. 

In  this  case  the  intervention  of  a greater  number  of  coefficients 
must  necessarily  take  place.  Among  these  a new  importance  is 
assumed  by  the  following  : — the  expression  of  the  movements  and 
instruments  in  words  ; the  formation  of  auditory  and  visual 
images  of  the  words  with  which  he  intends  to  express  his  thoughts 
and  emotions,  and  the  translation  of  the  images  of  the  words  into 
graphic  symbols.  These  images  are  furnished  by  other  cerebral 
cells  which  did  not  come  into  play  at  all  in  the  fencing-master’s 
movements  of  attack  and  defence. 

This  clearly  shows  that  to  obtain  a wider  co-ordination  of  move- 
ments and  to  attain  a higher  grade  of  motor  function  it  is  requisite 
that  there  be  not  only  differentiation  of  the  same  organs  of  the 
cerebral  cortex,  but  also  the  indispensable  assistance  of  other 
factors,  or,  as  one  might  say,  the  work  of  special  workmen  : division 
of  labour  and  co-ordination  of  the  workers. 

Another  example  may  be  brought  forward  : the  visual  organ 
appears  in  the  lower  animals,  even  in  some  protozoa  (Pouchet, 
Engelmann)  as  the  so-called  ocular  spots,  composed  of  pigmented 
cells  which  have  the  property  of  fixing  light,  and  are  in  turn  covered 
by  a refracting  substance  which  by  its  disposition  and  form  con- 
centrates and  directs  the  light.  The  ocular  spots  in  other  higher 
series  of  animals — e.g.,  the  more  developed  medusae  — are  not 
only  covered  by  refracting  media,  but  reach  a notable  degree  of 
organization. 


INTRODUCTION 


13 


These  eyes,  although  still  simple,  by  the  aid  of  a more  or  less 
limited  number  of  retinal  rod  cells  (in  some  arachnoids)  assume 
relations  with  small  ganglionic  groups,  these  becoming,  in  the  course 
of  succeeding  developments,  the  optic  ganglia  of  the  insects  and  the 
optic  lobes  as  met  with  in  the  vertebrates  (reptiles,  birds,  etc.). 
In  mammals,  in  addition  to  the  optic  lobes  which  furnish  some  factors 
indispensable  for  vision — perfected  as  it  is  in  them — we  find  in  the 
cerebral  mantle,  and  this  especially  in  the  higher  mammals,  a visual 
area  entirely  new  and  distinct  from  the  motor,  tactile,  and  auditory 
areas.  Meanwhile,  the  numerous  eyes  of  some  insects  do  not 
furnish  such  a perfect  vision  as  the  eyes  of  the  higher  mammals  ; 
their  sight  is  of  a low  grade,  and  probably  lacks  the  power  of 
accommodation  (Lubbock)  and  of  distinguishing  the  contour  of 
objects  (Forel). 

In  birds  and  mammals  sight  becomes  increasingly  more  perfect, 
and  one  region  of  the  cerebral  mantle  becomes  always  more  differen- 
tiated from  the  others,  for  the  visual  function. 

In  man  one  finds  the  visual  area  not  only  much  extended,  but 
also  highly  differentiated  as  compared  with  that  of  reptiles,  birds, 
and  even  higher  mammals. 

It  is  by  its  greater  development  and  its  progressive  differen- 
tiation that  the  brain  of  man  possesses  that  which  is  barely  outlined 
in  the  brain  of  birds,  and  which  is  only  a little  more  evident  in  that 
of  mammals — viz.,  the  visual  area,  which,  like  all  the  other  areas,  is 
functionally  distinct  and  differentiated  into  so  many  different  areas. 
Thus,  there  are  areas  for  the  sensation  of  light  and  colour,  form  and 
volume ; others  for  the  concrete  images  of  objects,  for  locality,  and, 
lastly,  for  the  graphic  images  of  speech. 

Indeed,  it  is  through  the  last-named  that  man  is  able  with  his 
sight  to  sum  up  so  great  a part  of  Nature,  and  reproduce  it  not  only 
with  the  artist’s  colours,  but  also  with  words  which  reflect  Nature 
in  a psychic  form  so  brilliant  as  Byron,  Leopardi,  and  many  others 
have  done. 


4.  The  Closer  Association  between  the  increasing  Number  of  Nerve- 

Elements  the  Higher  the  Grade  of  the  Function  to  be  fulfilled. 

Such  a marvellous  result  as  the  above— the  differentiation,  on 
the  one  hand,  and  the  great  complexity  of  the  products  of  action  of 
the  cerebral  cells  on  the  other — would  not  be  possible  did  there  not 
exist  associative  paths  which  open  up  innumerable  communica- 
tions between  the  millions  of  cells— which  are  so  many  units  of 
specific  energies — or  between  the  nervous  reticula  in  such  a number 
of  combinations  as  is  almost  beyond  the  possibility  of  calculation. 
By  means  of  these  paths  every  brain  cell  can  put  itself  in  direct  or 
indirect  relation  with  all  the  others,  not  only  of  the  cortex,  but  of 
all  the  vast  dominions  of  the  nervous  system. 


PSYCHIATRY 


One  may  judge  what  a wealth  of  communications  a group  of 
nerve  cells  calls  into  play  in  order  to  invoke,  under  the  influence 
of  one  stimulus,  the  co-operation  of  others,  and  still  others,  so  as  to 
bring  forth  the  highest  products  of  the  understanding  which  are 
possible  through  the  association  of  cell  labour. 

The  staining  methods  of  Golgi,  Cajal,  Nissl,  and  Apaty  demon- 
strate vividly  the  wealth  of  associative  paths  formed  by  means  of 
the  protoplasmic  and  axis-cylinder  processes.*  The  number  and 
arborizations  of  the  protoplasmic  processes  increase  with  the  degree 
of  evolution  of  the  animal  species. 


5.  The  Formation  of  Functional  Hierarchies  on  the  General  Law 
of  Greater  Aptitude  for  Government  of  the  other  Functions. 

The  work,  however,  is  not  equally  distributed  over  all  the  cerebral 
workers.  Some  of  them  are  assigned  a special  office,  and  they,  by 
the  nature  of  this  office,  exercise  a preponderating  influence  upon  all 
the  others  concerned  in  a complex  function. 

I entrust  the  demonstration  of  this  assertion  to  an  example 
which  I have  culled  from  the  physiopathology  of  language,  because 
I find  no  other  source  which  has  equally  close  connections  with  the 
intellect. 

Speech,  which  assumes  a significance  sometimes  sublime,  some- 
times arbitrary,  in  the  mind  of  the  poet,  theologian,  and  meta- 
physician, has  been  reduced  to  its  elements  by  the  pathologist,  and 
we  have  come  to  know  that  it  is  one  of  the  most  complex  products 
of  the  combined  labour  of  the  brain,  which  here  acts,  not  as  a func- 
tional unit,  but  as  the  synthetizer  of  the  specialized  products  of 
many  of  its  parts.  Speech  supposes  a preformed  conception  of 
what  one  wishes  to  express,  and  in  the  formation  of  this  conception 
there  co-operate  an  immense  number  of  cells  of  different  sensory 
and  motor  areas  of  the  cortex,  besides  those  sometimes  of  the  frontal 
lobes,  the  auditory,  visual,  and  kinsesthetic  images  of  each  word 
pronounced,  the  motor  discharge  from  the  motor  centre  of  articula- 
tion, and  the  graphic  discharge  from  the  motor  centre  of  writing. 
All  these  images  or  senso-motor  components  of  speech  possess  their 
respective  centres  in  the  cerebral  cortex,  each  distinct  from  the 
other.  As  the  maj  ority  of  men  learn  to  spea  k by  hearing — that  is,  by 
receiving  and  fixing  the  acoustic  images  of  the  words  pronounced  by 
others — the  differentiation  of  a centre  for  the  images  in  the  auditory 
area  of  the  cerebral  cortex  proceeds  in  concert  with  the  formation 
of  a centre  differentiated  for  the  articulation  of  words,  and  much 

* Such  a general  question  as  this  is  but  little  affected  by  the  discussion 
now  raging — in  consequence  of  the  works  of  Apaty,  Bethe,  Held,  on  the  one 
side,  and  Cajal  and  Van  Gehuchten  on  the  other — around  the  doctrine  of  the 
neurone  in  the  sense  of  Waldeyer.  or  the  nervous  reticulum  according  to 
Apaty. 


INTRODUCTION 


15 


precedes  that  of  a centre  for  reading  and  another  for  writing.  The 
first  (centre  for  acoustic  images),  being  the  oldest,  is  consequently 
the  most  stable  in  organization.  The  last  two  centres  (reading 
and  writing),  which  are  differentiated  on  more  or  less  remote 
areas  of  the  brain,  are  subordinate  to  the  centre  for  the  acoustic 
images  of  speech.  Accordingly,  while  a lesion  of  either  of  these 
last-named  centres  gives  rise  to  suppression  of  the  specific  function 
of  that  centre  only,  and  to  little  or  no  extent  disturbs  that  of  the 
others,  a lesion  of  the  centre  for  the  acoustic  images  of  speech 
suppresses  not  only  its  own  specific  function,  but  interdicts  or 
disturbs  that  of  all  others  taking  part  in  the  formation  of  speech. 
Seeing  also  that  language  is  spoken  before  it  is  written,  the  centre 
for  writing  is  subordinate  to  that  for  articulate  speech.  The  latter 
being  destroyed,  the  former  ceases  to  functionate  (Lichtheim). 
Biology,  then,  has  succeeded  in  discovering  not  only  the  law  of 
division  of  labour  in  the  development  of  the  brain,  but  also  that  of 
the  different  hierarchical  dignity  of  some  in  the  function  of  the 
whole. 

In  psychic  life,  in  proportion  as  the  mental  capital  of  ideas  and 
aptitudes  increases,  the  marvellous  functional  mechanism  adds  to 
its  complication  by  introducing  new  functions  which  co-ordinate 
themselves  with  those  pre-existing,  in  order  to  furnish  a more 
complex  product.  The  more  numerous,  associated,  and  educated, 
the  diverse  factors  from  which  it  emanates,  the  higher  is  the  dignity 
of  the  function.  Thus,  simple  sensations  combine  in  the  process 
of  perception.  From  the  perceptions,  and  always  by  way  of  associa- 
tion of  the  recent  products  with  the  older  perceptions,  we  arrive  at 
concrete  notions,  and  from  these,  step  by  step,  at  the  highest  abstrac- 
tions to  which  the  human  mind  can  attain.  Personality,  as  we  shall 
see  in  another  part  of  this  work,  is  only  the  product  of  the  physio- 
logical fusion  of  all  the  functions  of  life  synthetized  and  summarized 
by  the  nervous  system. 

When  man  of  the  sensory  type  advances  to  that  of  the  con- 
ceptive,  it  is  from  the  latter  side  that  the  government  of  the  sensory 
sphere  arises.  The  conceptions  are  like  centres  of  planetary  systems 
surrounded  and  followed  in  their  orbital  course  by  a greater  or  less 
number  of  satellites  (secondary  conceptions  and  concrete  images), 
whose  movements  are  regulated  by  the  greater  star,  so  long  as  they 
are  not,  by  reason  of  decompositions  and  recompositions,  estab- 
lished as  new  ideative  systems,  which  in  their  turn  regulate  the 
motion  of  their  respective  satellites. 

A great  number  of  mental  affections  are  the  consequences  of 
the  infringement  of  the  law  of  association  and  physiological  fusion 
of  the  products  of  individual  parts  of  the  nervous  system,  and 
of  the  suppression  of  the  regulative  influence  in  those  parts  of  the 
mantle  which  have  attained  the  highest  rank  of  synthetizing  and 
regulating  the  function  of  the  other  parts. 


i6 


PSYCHIATRY 


1 


6.  The  Reservation  of  all  Products  of  the  Cerebral  Functions  in  the  \ 
Great  Storehouses  of  the  Memory. 

" One  of  the  most  important  and  fundamental  functions  of  the 
brain  is  the  securing,  in  the  great  storehouses  of  the  organic  memory 
on  which  the  extent  and  quality  of  the  mind  and  character  depend, 
of  a reserve  of  all  the  products  of  the  cerebral  functions. 

A large  number  of  facts  elucidated  by  careful  observations  in 
hypnotic  and  subhypnotic  states,  besides  the  most  diverse  forms 
of  insanity,  demonstrate  clearly  that  mind  is  not  co-extensive  with 
consciousness. 

The  perceptions,  their  associations  and  reactions,  possess  a 
strong  intrinsic  influence,  outside  the  realms  of  consciousness,  on 
the  constitution  and  manifestation  of  the  personality,  just  as  atoms 
of  carbon,  oxygen,  hydrogen,  and  nitrogen  possess  the  affinity  for 
forming  an  organic  molecule. 

We  might  imagine  consciousness  to  be  a luminous  field,  relatively 
small  and  traversed  in  a unit  of  time  by  a somewhat  limited  number 
of  mental  components — perceptions,  emotions,  reactions,  and 
associated  and  combined  products,  which,  however,  are  in  constant 

motion.  . . 

A series  of  stimuli  operating,  and  a nervous  system  receiving, 
registering,  transmitting,  and  associating  impressions,  are  essential  : 
conditions  to  the  acquirement  of  a mental  product.  In  order  to  ; 
arouse  a state  of  consciousness,  however,  there  is  requisite  a certain  ' 
degree  of  intensity  of  stimulation,  external  or  internal,  or  the  repeti-  , 
tion  of  a weaker  stimulus,  so  that  these,  being  aggregated,  may  _ 
enter  upon  the  consciousness.  Throughout  the  whole  realm  of 
Nature  there  is  nothing  which,  acting  on  the  nervous  system,  is 
absolutely  incapable  of  producing  an  effect.  Even  the  feeblest  ^ 
agents  determine  minimal  modifications  with  a tendency  to  enter  the  ; 
field  of  consciousness.  On  the  other  hand,  the  sensations,  besides  . 
autochthonous  products  of  associations,  either  do  not  reach  the  field  | 
of  consciousness,  or  occupy  it  only  for  a short  time  ; then,  as  they  are  j 
succeeded  by  new  sensations  which  reach  the  threshold,  they  are  | 
driven  into  subconsciousness  and  thence  into  unconsciousness.  | 

Each  idea,  meanwhile,  like  each  emotion,  has  contracted  in-  j 
dissoluble  relations  with  the  organic  ego,  and  in  passing  into  the  j 
unconsciousness  carries  with  it,  in  a state  of  latency,  a certain 
quantity  of  the  light  of  consciousness  and  a tendency  to  return  into  | 
the  field  of  the  latter  ; the  more  impressive  its  first  incursion  upon 
the  consciousness,  the  longer  its  stay  there,  the  more  light  absorbed 
and  drawn  with  it  in  passing  into  the  unconsciousness,  and  the  more 
numerous  and  powerful  the  associations  contracted  with  the  organic  | 
ego  and  with  the  present  and  past  of  the  psycho-organic  personalit}/ , 
the  stronger  is  its  tendency  to  return.  These  ideas  and  emotions  | 
form  the  preconscious  sphere,  and  furnish  to  the  personality  the  | 


INTRODUCTION 


17 


points  of  rendezvous  and  departure.  It  is  important  to  note  that 
objects  and  their  relations,  synchronous  or  successive,  pass  into  the 
unconsciousness  in  the  same  order  as  they  exist  in  Nature  (Spencer) 
and  as  they  cross  the  field  of  consciousness  ; and  in  their  combina- 
tions they  are  regulated  by  the  laws  of  affinity  and  of  contrast,  so 
that  new  sensations,  similar,  dissimilar,  analogous,  and  contrasting, 
may  recall  from  the  unconsciousness  all  those  others  which  once  or 
oftener  have  had  passage  there.  Hence  the  wider  association  and 
the  progressive  augmentation  of  the  psychic  personality  which  takes 
root  in  the  unconsciousness  and  nourishes  itself  from  it.  Since, 
however,  the  unconsciousness  is  composed,  not  only  of  the  products 
elaborated  by  the  individual,  but  also  of  those  elaborated  by  the 
racial  ancestors,  although  the  brain  inherits  those  ancestral  dis- 
positions (associations  of  cell  groups  formed  by  exercise),  it  is  easy 
to  understand  what  extensive  organization  is  possible,  in  the  wide 
realms  of  the  unconsciousness,  between  the  present  and  past  of  the 
individual  and  the  past  of  the  race,  and  how  it  is  possible  that  from 
such  an  extensive  association  there  may  be  released  so  much  light 
that  the  consciousness  of  the  individual  is  itself  sometimes  thereby 
surprised.  One  of  the  sensory  factors  of  a complex  product  of  the 
understanding  may  have  traversed  the  field  of  consciousness  in  a 
state  of  simplicity,  or  may  always  have  remained  outside  it,  associ- 
ating itself  by  its  inherent  nature  with  the  individual  or  atavic 
residua.  In  any  case,  it  is  evident  that,  even  although  the  outer 
world,  intruding  itself  upon  and  augmenting  the  consciousness  with 
its  infinite  stimuli,  drive  back  into  the  unconsciousness  the  story  of 
the  individual,  still,  it  is  always  the  latter  which  bestows  the  greater 
brilliancy  upon  the  consciousness. 

The  historical  order  in  the  disposition  of  the  contents  of  the  great 
archives  of  the  unconsciousness,  the  ever-obseived  law  of  the  affinity 
'oi  the  constituent  elements  in  the  unconscious  processes  of  decom- 
position and  recomposition,  the  readiness  to  furnish  the  historical 
details  of  the  personality  when  demanded  by  the  consciousness  or 
the  environment,  are  indispensable  conditions  of  psychic  life, 
departure  from  which  gives  rise  to  mental  disorder. 

7.  The  Complete  Observance  of  the  Laws  of  Organic  Life,  etc. 

Life  is  maintained  by  organic  integration  and  disintegration  ; 
nolecules  are  assimilated  from  without,  and  take  the  place 
)f  others  which  become  eliminated.  Those  organisms  which 
issimilate  more  easily  and  eliminate  more  readily  the  products 
|)f  organic  disintegration  have  the  higher  life.  This  fact  and 
aw  has  its  counterpart  in  psychic  life  also.  Of  the  large  number 
!)f  impressions  arriving  at  the  receptive  centres,  and  perceived 
*r  transformed  in  the  great  central  crucible  of  the  psychic  work- 
hop  ; of  all  that  world  of  atoms  which  constitute  the  Milky  Way 


i8 


PSYCHIATRY 


of  the  mind,  always  in  process  of  formation,  only  some  are  utilized 
by  and  incorporated  in  the  mind,  which  through  these  is 
ever  advancing  further  in  the  consciousness  of  the  universe.  If, 
however,  these  impressions,  which  are  useless  or  dangerous,  be  not 
eliminated  from  the  field  of  the  consciousness,  but  accumulate  there, 
they  encumber  it,  impede  its  regular  action,  and  succeed  in  poison- 
ing the  mental  organism.  These  impressions,  useless  or  dangerous 
to  the  personality,  arriving  at  a point  in  the  perception  destitute  of 
assimilable  elements  and  of  any  formative  power  whatsoever,  or  at 
the  most  possessing  but  a scant  one,  soon  become  eliminated  by  the 
intrinsic  virtue  of  the  consciousness.  How  many  evolutions  of 
the  spirit  belonging  to  the  long  period  of  childhood  and  youth, 
which  respond  no  longer  to  the  degree  of  evolution  of  maturity, 
become  hidden  in  the  shades  of  the  unconsciousness  ! To  how 
many  once-enacted  scenes  that  now  offend  our  modern  sense  of 
ethics  do  we  refuse  to  give  countenance  ! All  these  psychic  com- 
ponents, which  we  may  liken  to  the  meteors  of  the  mental  universe, 
no  longer  form  an  active  part  of  our  mind,  and  either  no  longer  cross 
the  field  of  consciousness,  or  else  pass  the  threshold  of  perception 
at  a tangent  and  disappear  (elimination). 

Just  as  our  organism  takes  from  the  outer  world  the  assimilable 
matter  by  which  it  commences  to  develop,  and  by  which  it  is  ulti- 
mately perfected,  transforming  it  in  a thousand  ways,  so  the  under- 
standing is  nourished  and  developed  by  the  forces,  infinite,  various, 
and  capricious,  which  emanate  from  Nature. 

In  the  physical  organization  disintegration  and  assimilation  of 
the  material  from  without  takes  place  in  contact  with  that  forming  ^ 
the  organism.  In  the  mental  organism  those  mental  formations  of  = 
which  the  personality  is  already  constituted  are  broken  up  and 
reconstructed  under  the  influence  of  new  acquisitions.  The  series  of 
chemical  products  ranges  from  simple  bodies  to  protagon  ; psychic  , 
products  trom  the  simplest  sensations  to  the  most  abstract  concep-  ( 
tions.  The  body  eliminates  all  the  waste  products,  and  restores  to  | 
the  earth  the  useless  material  introduced  ; the  mind  eliminates  all  the  j 
useless  elements  of  psychic  compositions  and  decompositions,  and  » 
thrusts  away  into  the  realms  of  the  unconsciousness  those  which  are 
not  in  harmony  with  its  life  and  with  its  further  development  in 
relation  to  the  environment. 

The  active  nuclei  of  the  personality,  those  which  most  reflect  ‘ 
nature  and  environment  in  the  historical  moment  of  their  existence, 
exercise  a true  phagocytic  power  on  those  others  which  arrive  there 
like  detritus  from  the  great  forge  of  thought  in  the  social  and  physical 
environment.  Those  in  whose  consciousixess  this  phagocytic  and 
eliminating  power  is  defective — who  receive  into  their  consciousness 
all  that  falls  under  their  senses,  or  the  useless  products  of  decom-  | 
position  and  recomposition,  resemble  pulpy  organisms  impoverished 
by  parasiticism  and  enfeebled  by  slow,  insidious  poisoning. 


t 


INTRODUCTION  19 

Those  useless  mental  products  and  hurtful  perceptions  which 
instal  themselves,  accumulating,  chasing  one  another,  and  domin- 
ating the  consciousness,  destroy  the  balance  of  mental  life,  and  in- 
terfere with  the  course  of  thought,  feeling,  and  action. 

One  somewhat  large  class  of  psychic  disorders  is  represented  by 
hereditary  or  acquired  incapacity  to  free  one’s  self  from  the  percep- 
tions, thoughts,  emotions,  and  actions  which  are  useless  and  opposed 
to  the  consciousness.  These  furnish  the  proof  of  the  fundamental 
law  of  psychic  life. 

The  most  fundamental  laws  of  mechanics  and  of  physics  agree 
with  those  of  psychic  life.  Let  us  take,  for  example,  the  law  that 
velocity  is  in  direct  ratio  to  the  excito-motor  force  (initial  velocity) 
and  in  inverse  ratio  to  the  resistance.  This  can  be  psychologically 
demonstrated  thus  : a vigorous  idea,  an  intense  desire,  a strong 
sentiment,  can  earn  the  reward  denied  to  the  man  whose  thought  is 
feeble,  whose  desire  is  weak,  whose  sentiment  is  exhausted  (by 
greater  rapidity  or  velocity  of  the  action). 

Let  us  take  one  other  example  from  the  electric  battery.  We 
know  that  the  intensity  of  the  current  is  in  inverse  ratio  to  the  re- 
sistance and  in  direct  ratio  to  the  electro-motor  force. 

The  resistance  in  the  electric  battery  is  both  internal  and  external. 
The  external  belongs  to  the  larger  circuit  and  the  internal  to  the 
battery  itself  (smaller  circuit).  In  the  manifestations  of  the  mental 
being  we  can  likewise  recognise  two  forms  of  resistance — the  ex- 
ternal and  the  internal.  The  external  resistance  reaches  us  from 
the  environment,  the  internal  is  met  with  in  our  consciousness.  It 
is  easy  to  understand  the  external  resistance.  Every  action,  from 
the  most  simple  (any  act  of  prehension)  to  the  most  complex  (a 
scientific  research,  a colonial  enterprise),  has  implied  in  it  the  con- 
ception of  resistance.  That  the  internal  resistance  is  in  inverse 
ratio  to  the  excito-motor  force  is  proved  by  the  fact  that  a difficulty 
is  more  apparent  to  the  old  and  feeble  than  to  the  young  and 
vigorous. 

The  loss  of  self-confidence  at  the  moment  one  is  preparing  for  an 
undertaking,  or  the  intrusion  of  other  psychic  components,  especi- 
ally the  emotions  (fear),  induces  a diminution  in  the  rapidity  of  the 
action,  even  to  the  point  of  arrest.  It  is  by  the  same  principle  that 
compression  and  obstruction  of  a bloodvessel,  arterial  or  venous, 
lead  to  slowing  and  arrest  of  the  blood-current,  even  to  the  point  of 
thrombosis.  The  velocity  under  equal  conditions  is  in  inverse  ratio 
to  the  weight. 

If  small  desires  and  obvious  ideas  find  ready  actualization,  great 
conceptions  and  high  sentiments  require  a long  time,  and  often  the 
produce  of  many  brains  and  many  generations,  to  reach  the  standard 
of  universal  knowledge. 

The  useful  product  of  labour  is  in  combined  ratio  to  the  excito- 


2 — 2 


20 


PSYCHIATRY 


motor  force,  the  resistance  overcome,  and  the  weight  transferred. 
The  law  of  the  ramification  of  a current  into  different  conductors, 
or  of  a column  of  water  into  various  tubes  of  different  diameter,  and 
the  laws  of  resistance,  all  have  their  representatives  in  the  mental 
mechanism,  and  have  furnished  to  Wundt  the  subject-matter  of  one 
of  the  most  acceptable,  though  somewhat  abstruse,  books — ‘ Die 
Mechanik  der  Nerven  und  Nervencentren.’ 

If  a liquid  which  flows  in  a tube  under  a given  pressure  becomes 
distributed  in  several  tubes,  the  velocity  diminishes  in  proportion 
to  the  number  and  diameter  of  the  tubes.  In  like  manner,  the  in- 
tensity of  the  electric  current  is  altered  if  it  becomes  spread  over 
various  conductors.  The  analogous  law  regulating  the  phenomena 
of  mental  life  can  always  be  recognised  ; more  quickly  and  surely 
does  he  attain  the  end  of  his  individual  exertions  who,  under  equal 
conditions,  knows  how  to  collect  all  the  energies  a.t  his  disposal,  and 
direct  them  on  the  object  of  his  desires.  The  individual  who  dissi- 
pates energy  in  wavering  and  doubt  (internal  resistance),  because 
deficient  in  ready  perception  of  the  end,  the  means,  and  the  con- 
sciousness of  the  energies  at  his  own  disposal,  and  who  through  fear 
exaggerates  to  himself  the  extent  and  nature  of  the  difficulties  and 
dangers,  will  be  a laggard  on  whom  the  fortune  of  victory  will  never 
smile. 

A large  class  of  affections  is  met  with  in  individuals  who  see  only 
obstacles,  who  feel  only  difficulties  ; weak-minded  and  worthless, 
they  yield  to  the  slightest  stress.  They  are  weak  and  cowardly,  and 
sometimes  call  themselves  prudent  ; tormented  and  swayed  inces- 
santly by  doubt,  they  squander  their  already  much  weakened 
psychic  energies  (cerebrasthenia)  in  those  internal  struggles. 

Another  law  of  psychic  life  is  the  harmony  of  the  reciprocal 
relations  existing  between  body  and  mind. 

That  the  psychic  function  is  ingrafted  upon  the  great  trunk  of  the 
organic  functions,  and  is  affected  by  all  the  modifications  which 
occur  therein,  is  demonstrated  by  the  fact  that  all  the  organic  altera- 
tions have  their  equivalents  in  the  nervous  system  and  the  psychic 
personality. 

The  mind  adapts  itself  variously,  according  to  the  alterations  in 
the  external  and  internal  conditions ; humour  and  disposition 
change  through  physical  pain,  through  the  exhaustion  of  functional 
anomaly  of  an  organ,  as,  for  example,  the  stomach.  There  are  few 
disorders  of  the  molecular  interchange  which  do  not  produce  more 
or  less  notable  and  significant  disturbances  in  the  psychic  sphere — 
change  of  humour  (sadness,  ennui,  melancholy),  altered  mental 
disposition  (unaccustomed  rudeness,  lessened  communicativeness, 
colder  friendship),  diminished  aptitude  for  work,  increased  or  less- 
ened affectivity.  It  is  sufficient  to  mention  diabetes,  the  uric  acid 
diathesis,  oxaluria,  etc.  Sometimes,  when  the  individual  himself, 
by  his  strong  mental  organization,  does  not  show  moral  and  intellec- 


INTRODUCTION 


21 


tual  changes  worthy  of  consideration,  such  are  manifested  in  the 
offspring.  In  this  connection  it  is  a highly  significant  fact  that  in 
many  families  the  psycho-physical  degeneration  arises  from  an  altered 
chemistry  in  the  ancestors.  The  old  physicians  had  already  noted 
for  a long  time  that  many  neuropsychic  forms  (neuralgia,  etc.) 
originated  in  the  gouty  diathesis.  Many  to-day  recognise  a uric 
acid  or  arthritic  genesis  of  progressive  paralysis  of  epilepsy,  etc. 

It  will  be  sufficient  to  mention  the  psychic  impoverishment  of 
the  jaundiced;  the  dementia  of  the  subjects  of  myxoedema  (thyro- 
pravia) ; the  imperfections  and  the  frequent  failure  of  the  highest 
mental  products  in  individuals  slightly  alcoholized ; psychic  para- 
lyses which  may  progress  with  the  gradual  dissolution  of  the  per- 
sonality up  to  complete  abolition  of  the  mind  in  coma  ; the  excited 
imagination  of  one  under  the  influence  of  coffee  or  tea  for  the  first 
time  ; the  depression  of  all  the  energies  of  the  neurasthenic,  during 
the  long  hours  of  digestion,  by  absorption  of  anomalous  products 
of  a disordered  digestion — these  examples  are  sufficient  to  make  us 
appreciate  thoroughly  the  reciprocal  dependency  and  the  important 
bearing  of  the  functions  of  the  material  interchange  upon  the  psychic 
functions.  We  accordingly  find  here  great  variety  in  susceptibility 
— strongly-organized  individuals  whose  personal,  intellectual,  and 
moral  nuclei  are  incapable  of  decomposition,  and  who  pass  through 
the  most  diverse  circumstances,  external  and  internal,  preserving 
always  the  same  figure  ; others,  composed  of  more  unstable  com- 
ponents, which  become  decomposed  at  every  action  of  new  factors, 
internal  and  external,  on  this  account  appear  extremely  changeable. 
The  latter  can  be  arranged  in  series  from  the  opportunists  of  life  to 
the  inconclusives.  Not  only  are  the  changes  in  the  former  not  con- 
firmed, but  rather  should  we  say  that  they  do  not  become  evident, 
because  they  do  not  overcome  the  strong  affinity  of  the  stable  and 
refractory  compounds  of  the  well-constituted  personality.  But 
wherever  an  organic  change  occurs  it  alters  something  in  the  com- 
plexity of  the  psychic  personality,  which  may  cross  the  threshold  of 
consciousness,  be  reflected  upon  the  physiognomy  and  on  the  mus- 
cular and  mental  disposition,  and  be  noticed  by  others  ; this  does 
not  arouse  particular  states  of  consciousness  and  sensible  altera- 
tions. 

The  organic  sphere  and  its  constitution  are  reflected  in  the  psychic 
sphere  so  far  as  regards  the  disposition  and  tone  of  the  mind. 
Want  of  harmony  of  the  body,  and  especially  asymmetry  of  the  brain, 
are  transcribed  as  discords  and  asymmetries  of  psychic  life.  The 
extirpation  of  any  organ  whatever  induces  a modification  in  the  ex- 
tent and  disposition  of  the  psychic  personality.  Castration  in  the 
male  or  oophorectomy  in  the  female  changes  the  aspect  and  char- 
acter of  the  unfortunate  being.  Not  infrequently  a certain  slow 
alteration  is  likewise  to  be  met  with  in  those  who  in  adult  life  have 
lost  a limb.  I have  not  seen  anyone  perfectly  constituted,  intellec- 


22 


PSYCHIATRY 


tually  and  morally,  among  those  who  presented  a congenital  de- 
formity of  one  of  the  limbs.  This  does  not  conflict  with  any  possible 
exception.  Such  a fact  has  been  confirmed  by  anatomico-patho- 
logical observations,  either  of  agenesis  of  a given  part  of  the  brain  in 
relation  to  the  arrest  of  development  of  a limb,  or  of  those  cases  in 
which  a disease  of  infancy  which  suppresses  or  paralyzes  a limb  (as 
in  acute  poliomyelitis  of  infancy)  induces  atrophy  of  the  correspond- 
ing part  of  the  cerebral  cortex.  The  corporal  asymmetry  finds  its 
counterpart  in  an  analogous  cerebral  asymmetry  which  in  its  turn 
betrays  itself  as  a psychic  asymmetry,  the  miost  classic  manifestation 
of  which  is  epilepsy. 

If  we  examine  the  question  from  another  side,  we  shall  find  the 
most  perfect  correspondence  between  the  psychic  and  somatic 
phenomena  of  a great  number  of  nervous  affections.  The  instant 
nature  of  the  common  epileptic  attack  finds  a counterpart  in  the 
impulsive  nature  of  the  character  of  the  epileptic,  the  wild  cry 
of  the  ordinary  accession  in  the  savage  act  of  the  psychic  accession. 
The  nervous  and  unconscious  discharge  of  the  convulsion  itself  is 
worthy  of  the  terrifying  hallucination,  or  a blood-curdling  thought 
as  of  fifty  poniard  stabs  being  inflicted  upon  an  innocent  victim. 
Unconsciousness  is  present  in  all  these  manifestations  which  are 
equivalents.  The  cerebral  asymmetry  and  the  psycho-somatic 
degeneration  are  the  common  substratum  ; hatred  of  God  and  man, 
cloaked  by  religion  and  reverence,  is  common  to  all  the  forms. 

The  same  thing  is  observed  in  hysteria.  Here  we  meet  with  two 
orders  of  symptoms — somatic  and  psychic.  Both  are  characterized 
by  the  same  feature — mobility.  To-day  there  is  aucesthesia  of  an 
entire  side,  to-morrow  of  a limb  only  ; another  day  of  yet  another 
part  of  the  body.  It  may  vary  in  intensity,  or  it  may  be  that  one 
kind  of  sensibility  only  is  defective  ; frequently  such  hysterica.1 
disorders  alternate  capriciously. 

One  fancy  induces  paralysis,  another  will  cause  it  to  disappear 
and  will  produce  contracture.  A misfortune,  a shock,  a blow,  an 
emotion,  an  insinuating  suggestion,  a strict  command,  can  dispel 
or  reproduce  the  most  varied  symptoms. 

The  mind  behaves  in  like  manner.  High  spirits  and  low  spirits 
succeed  one  another,  and  alternate  without  objective  cause  ; laugh- 
ing and  weeping,  confidence  and  diffidence,  sympathy  and  antipathy, 
love  and  hatred,  truth  and  falsehood,  simulation  and  dissimulation, 
enthusiasm,  heroism,  misanthropy,  emerge  from  hysteria  in  a kind  of 
animated  merry-go-round  in  which  men  and  things  are  frequently 
involved,  and  which  displays  itself  in  forms  varying  from  the  ecstasy 
of  Saint  Theresa  or  the  heroism  of  Joan  of  \rc  to  the  simulation  of 
Madame  X.  and  of  Count  Paolo.  These  two  forms  of  hysteria,  the 
somatic  and  the  psychic,  coexist,  succeed  one  another,  and  alternate 
time  and  again. 

The  same  thing  occurs  in  the  common  chorea  of  Sydenham. 


INTRODUCTION 


23 


The  disturbances  characterizing  this  affection  are  common,  in  dif- 
ferent proportion,  to  body  and  mind.  Inco-ordinate  and  purpose- 
less muscular  explosions  exist  alongside  emotional,  volitional,  or 
ideative  explosions  ; a series  of  choreic  feints  are  superimposed 
upon  a series  of  psychic  attitudes  with  which  they  are  in  strict 
relation. 

Emotional  flashes,  isolated  and  fleeting  thoughts,  destitute  of 
association,  like  many-coloured  soap-bubbles  blown  in  the  air  ; 
volitional  impulses  and  psychic  arrests  ; oases  and  deserts  in  the 
consciousness,  which  is  disturbed  and  entirely  upset — such  is  the 
picture  of  the  choreic.  Just  as  no  movement  is  co-ordinated  and 
rational,  and  capable  of  attaining  a preconceived  end,  so  no  thought 
expresses  a purpose,  no  mentalization  is  the  reflex  of  external 
circumstances.  The  entire  being,  with  the  relations,  from  the  most 
elementary  movement  to  the  most  complex  conception  of  which  the 
individual  is  capable,  is  unstable,  and  sometimes  dispersed  in  a series 
of  useless  and  valueless  products  which  have  all  the  same  significa- 
tion— the  temporary  liquefaction  of  the  nervous  system  in  its  twofold 
and  correlative  manifestation  of  somatic  and  psychic  functions. 


PART  I 


CHAPTER  I 

ANATOMICAL  SKETCH  OF  THE  CEREBRAL  MANTLE  AND 
OF  THE  SUBMANTELLAR  WHITE  SUBSTANCE 

I have'  mentioned  in  the  Introduction  that  the  cerebral  mantle 
possesses  quite  a long  story  of  development.  From  that  of  the 
primary  vertebrates,  which,  in  comparison  with  the  human  mantle, 
contains  few  cells,  it  becomes  gradually,  not  only  more  complicated, 
but,  above  all,  richer  in  anatomical  components,  with  an  accompany- 
ing formation  of  convolutions  and  the  appearance  of  nerve  elements 
of  various  forms  and  dispositions. 

This  is  not  the  place  to  describe  in  great  detail  all  the  phases  of 
the  development  of  the  mantle,  either  throughout  the  zoological 
orders  or  in  its  various  grades  of  evolution  in  the  human  subject, 
from  the  appearance  of  the  anterior  vesicle  to  the  full  development 
of  the  brain.  The  sole  object  of  the  first  part  of  this  book  is  to 
expound,  in  the  most  condensed  and  synthetic  manner,  the 
mechanism  whereby  the  brain  fulhls  its  function,  and  for  a clear 
notion  of  this  we  must  have  a knowledge  of  the  cerebral  archi- 
tecture, at  least  in  its  general  lines.  By  following  this  plan,  the 
semeiology  of  the  mental  affections  and  the  clinical  forms  which 
these  assume  will  find  their  surest  and  most  rational  explanation 
altogether  beyond  the  confines  of  clinical  empiricism. 

A section  through  the  cerebral  peduncles,  as  far  as  possible  in 
front  of  their  insertion  into  the  pons,  and  another  longitudinal 
section  in  the  median  line  of  the  corpus  callosum,  divide  the  cerebral 
hemispheres  or  anterior  brain  (including  the  intermediate  brain 
[optic  thalamus])  from  the  mid  brain  (corpora  quadrigemina)  and 
the  posterior  brain  (and  after  brain).  The  cerebral  hemispheres 
present  three  aspects,  each  of  which  is  divisible  into  more  or 
less  definite  anatomical  provinces,  and  also  into  phj^siological 
provinces  which  are  not  so  well  defined.  These  two  provinces  do 
not  coincide  with  one  another,  and  therefore  we  shall  briefly  describe 
the  former,  and  adopt  the  simplest  method  of  arriving  at  a know- 
ledge of  the  latter. 


24 


ANATOMICAL  SKETCH  OF  CEREBRAL  MANTLE  25 


External  Aspect  of  the  Cerebral  Hemisphere 

Here  we  can  distinguish  four  anatomical  provinces  separated  by 
deep  sulci  or  fissures — the  fissure  of  Sylvius,  the  fissure  of  Rolando, 
and  the  occipito-parietal  fissure.  Of  the  four  resulting  anatomical 
provinces,  one — the  frontal  province — is  neatly  and  precisely 
defined  ; the  other  three  can  be  distinguished  only  by  extending 
the  given  fissures  as  imaginary  lines  in  definite  directions.  The 
three  provinces  distinguished  in  this  last-named  manner  are  the 
parietal,  the  temporal,  and  the  occipital. 

Frontal  Region  or  Province. — This  is  well  defined  below  by 
the  fissure  of  Sylvius,  behind  by  the  fissure  of  Rolando  or  sulcus 
centralis,  and  above  by  the  superior  margin  of  the  hemisphere.  It 
is  composed  of  four  convolutions  : 

1.  The  ascending  frontal  convolution  (gyrus  centralis  anterior)  is 
situated  between  the  fissure  of  Rolando  and  the  prefrontal  sulcus 
(sulcus  precentralis),  and  extends  upwards  to  the  superior  margin 
of  the  hemisphere,  and  downwards  to  the  fissure  of  Sylvius,  where 
it  contributes  to  the  formation  of  the  frontal  operculum. 

2.  The  superior  frontal  convolution  (gyrus  frontalis  superior), 
commencing  at  the  inferior  aspect  of  the  hemisphere,  where  we  shall 
meet  it  again,  contributes  to  the  formation  of  the  frontal  pole,  and, 
following  the  curve  of  the  hemisphere  between  the  interhemispheric 
margin,  which  bounds  it  along  its  whole  length,  and  the  superior 
frontal  sulcus  (sulcus  frontalis  superior),  which  separates  it  from 
the  convolution  below,  it  joins,  after  broadening  out,  the  ascending 
frontal  convolution  (foot  or  pes  of  the  superior  frontal  convolution). 

Sometimes  the  pes  is  separated  from  the  ascending  frontal  con- 
volution by  a sulcus  (sulcus  prefrontalis  superior). 

3.  The  middle  frontal  convolution  (gyrus  frontalis  medius)  takes  part 
also  in  the  formation  of  the  frontal  poles ; it  follows,  with  a shorter 
radius,  the  curve  of  the  superior  frontal,  from  which  it  is  separated 
by  the  superior  frontal  sulcus  ; finally,  it  terminates  in  a broad 
base  (pes)  at  the  ascending  frontal  convolution,  from  which  it  is 
separated  for  a considerable  distance  by  the  superior  prefrontal 
sulcus  (sulcus  precentralis  superior),  and  is  distinguished  from  the 
inferior  frontal  convolution  by  means  of  the  inferior  frontal  sulcus. 

4.  The  inferior  frontal  convolution  joins  the  inferior  part  of  the 
ascending  frontal  with  which  it  is  in  continuation  in  the  opercular 
region  (pes).  It  exactly  embraces,  with  its  foot  folded  bac.t:  on  its 
inferior  margin,  the  ascending  branch  of  the  fissure  of  Sylvius.  It 
is  limited  interiorly  by  the  fissure  of  Sylvius  ; in  front  it  forms  the 
rounded  extremity  whereby  the  external  face  becomes  continuous 
with  the  orbital  surface  of  the  hemisphere,  and  assists  also  in  the 
formation  of  the  frontal  pole  along  with  the  other  two  convolutions  ; 
from  the  middle  frontal  convolution  it  is  separated  by  the  inferior 
frontal  sulcus  (sulcus  frontalis  inferior). 


26 


PSYCHIATRY 


Parietal  Region  or  Province. — To  this  province  we  can 
assign  the  following  boundaries  : In  front,  the  fissure  of  Rolando  ; 
above,  the  superior  hemispheric  margin  included  between  the  fissures 
of  Rolando  and  the  occipito-parietal  fissure  {sulcus  parieto-occipitalis\\ 
below,  from  before  backwards  by  (i)  the  fissure  of  Sylvius  where  it 
runs  horizontally,  (2)  an  imaginary  line  which  represents  its  pro- 
longation backw^ards  to  a point  of  junction  with  the  lateral  occipital 
sulcus,  and  (3)  a portion  of  the  latter,  having  likewise  a horizontal 
direction  and  usually  found  in  line  with  the  horizontal  part  of  the 
fissure  of  Sylvius  ; behind,  the  province  is  bounded  by  {a)  the 
inferior  portion  of  the  interparietal  sulcus,  considered  by  some 
anatomists  a distinct  anterior  occipital  sulcus,  but  which  in  the 
majority  of  brains  is  continuous  with  the  interparietal  sulcus;  and 


by  {h)  the  occipito-parietal  fissure  and  its  imaginary  prolongation 
to  meet  the  interparietal  fissure. 

All  this  extensive  province  may  be  divided  into  various  con- 
volutions and  lobes  : 

1.  The  ascending  parietal  convolution,  or  gyrus  centralis  posterior, 
is  separated  in  front  from  the  frontal  lobe  by  the  fissure  of  Rolando, 
and  is  parallel  to  the  ascending  frontal  convolution,  whilst  behind 
it  is  distinguished  from  the  remaining  part  of  the  parietal  lobe  by 
the  post-Rolandic  sulcus,  or  sulcus  retrocentralis,  not  always  well 
developed  in  its  whole  length  ; above,  it  reaches  the  interhemis- 
pheric  border  ; below,  it  forms  the  parietal  operculum,  a posterior 
continuation  of  the  frontal.  The  rest  of  the  parietal  region  is 
divided  into  two  parts  by  the  interparietal  sulcus  {sulcus  inter- 
parietalis),  which  forms  a marked  curve  with  its  convexity  looking 
downwards  and  forwards. 

2.  The  superior  parietal  lobule,  comprising  what  existed  above 


ANATOMICAL  SKETCH  OF  CEREBRAL  MANTLE  27 


the  sulcus  mentioned,  is  well  delimited  by  the  interhemispheric 
margin  above,  the  interparietal  sulcus  below,  the  post-Rolandic 
sulcus  in  front  {sulcus  retro  centralis),  and  the  occipito-parietal 
fissure  behind. 

3.  The  inferior  parietal  lobule  consists  of  the  remainder  of  the 
parietal  region  below  the  sulcus  interparietalis,  and  its  limits  in 
front,  behind,  a.ud  below  are  those  already  assigned  to  the  parietal 
region.  This  lobule  is  by  some  divided  into  two,  and  by  others 
into  three,  convolutions  : 

(a)  The  supramarginal  convolution  {gyrus  supramarginalis),  em- 
bracing the  ascending  branch  of  the  fissure  of  Sylvius  ; more 
behind  and  above  is  found — 

ih)  The  angular  convolution  or  gyrus  {gyrus  angularis),  which 


Fig.  6. — Insula  (at  the  Bottom  of  the  Exposed  Fissure  of  Sylvius). 


embraces  the  ascending  branch  of  the  superior  temporal  sulcus  (or 
parallel  sulcus,  according  to  some  anatomists). 

{c)  The  posterior  parietal  convolution  or  gyrus  {gyrus  parietalis 
posterior),  which,  according  to  some  (Edinger),  is  a distinct  convolu- 
tion, but  ciCcording  to  others  forms  a single  convolution  in  combi- 
nation with  the  angular  gyrus  (Dejerine  and  others). 

Temporal  Region  or  Province. — This  is  well  limited  above 
for  its  anterior  two-thirds  by  the  fissure  of  Sylvius,  below  by  the 
margin  of  the  hemisphere.  In  front  it  forms  the  temporo-sphe- 
noidal  pole,  but  has  no  precise  limits  behind  and  above  or  posteriorly, 
where  it  is  fused  with  the  parietal  and  occipital  regions.  We  have 
already  mentioned  the  imaginary  line  which  divides  the  temporal 
region  above  and  behind  from  the  parietal  ; behind,  as  the  line 
of  limitation,  we  might  imagine  one  representing  the  prolongation 


28 


PSYCHIATRY 


of  the  anterior  occipital  sulcus  (sulcus  occipitalis  anterior)  to  a point 
of  junction  with  the  preoccipital  notch.  This  region  is  divisible  into 
three  convolutions,  recognisable  in  almost  all  brains. 

1.  The  superior  temporal  convolution  (^gyrus  temporalis  superior), 
situated  between  the  fissure  of  Sylvius  above  and  the  superior 
temporal  sulcus  below  (.sulcus  temporalis  superior). 

2.  The  middle  temporal  convolution  (.gyrus  temporalis  medius),  situ- 
ated between  the  superior  temporal  sulcus  and  the  inferior  temporal 
sulcus  (.sulcus  temporalis  inferior),  which  separates  it  from — 

3.  The  inferior  temporal  convolution  (^gyrus  temporalis  inferior), 
situated  below  the  given  sulcus  and  forming  the  inferior  border 
of  the  hemisphere.  All  those  three  convolutions  enter  into  the 
formation  of  the  temporo-sphenoidal  pole,  and,  leaving  out  the 
imaginary  line,  become  fused  posteriorly  with  the  inferior  parietal 
lobule  and  with — 

The  Occipital  Region. — This  is  limited  in  front  by  the  sulci 
and  imaginary  lines  described  as  the  posterior  boundary  of  the 
parietal  and  temporal  regions  ; behind  and  below  by  the  margin  of 
the  hemisphere.  Three  convolutions  take  part  in  its  formation  : 

1.  The  first  occipital  convolution  (.gyrus  occipitalis  /.),  which  is 
bounded  by  the  anterior  occipital  sulcus  in  front,  the  interhemi- 
spheric  border  behind,  the  occipito-parietal  fissure  above,  and  the 
occipito-lateral  sulcus  below.  Its  direction  is  almost  vertical. 

2.  The  second  occipital  convolution  (.gyrus  occipitalis  II.)  is  situ- 
ated almost  horizontally  between  the  lateral  occipital  sulcus  above 
(.sulcus  occipitalis  lateralis)  and  the  inferior  occipital  sulcus  below 
(second  occipital  sulcus  of  some  anatomists),  being  separated  by  it 
from — 

3.  The  third  occipital  convolution  (^gyrus  occipitalis  III.),  also 
situated  almost  horizontally,  and  forming  the  inferior  border  of 
the  hemisphere,  as  far  as  the  preoccipital  sulcus,  which  separates 
it  in  front  from  the  inferior  temporal  convolution. 

On  exposing  the  fissure  of  Sylvius  by  depressing  the  temporal 
lobe  anteriorly  and  raising  the  fronto-parietal  operculum,  another 
region,  quite  hidden  in  well-developed  brains,  and  forming  the  floor 
of  the  fissure,  comes  into  view.  It  consists  of  from  five  to  seven 
small,  almost  rudimentary,  convolutions,  disposed  like  a fan  in  a 
direction  almost  oblique  from  below  upwards.  This  province,  of 
great  importance  from  a physiological  point  of  view,  is  the  so- 
called  insula  (Fig.  6). 


Internal  Aspect  of  the  Cerebral  Hemisphere 

On  the  internal  face  of  the  hemisphere  we  can  distinguish  with 
precision  a fronto-parietal  region,  a limbohippo-campic  region, 
and  an  occipital  or  occipito-temporal  region  (Fig.  7). 

The  fronto-parietal  region  is  formed  by  the  iuternal  aspect  of 


ANATOMICAL  SKETCH  OF  CEREBRAL  MANTLE  29 


the  superior  frontal  convolution  {gyrus  frontalis  superior)  already 
seen  on  the  external  surface.  This  convolution  forms  the  border 
of  the  hemisphere  for  more  than  the  anterior  third  of  its  entire 
length,  and  is  separated  from  the  limbic  region  by  the  calloso- 
marginal  sulcus  {ramus  marginalis  of  the  sulcus  cinguli).  Behind, 
it  merges  into  the  para-Rolandic  lobule  ilohula  paracentralis),  which, 
on  the  internal  face  of  the  hemisphere,  represents  the  Rolandic 
convolutions.  This  lobule  in  turn  is  bounded  above  by  the  inter- 
hemispheric  border,  in  continuation  with  that  of  the  frontal  region  ; 
below  by  the  calloso  - marginal  sulcus  {sulcus  cinguli — Edinger), 
which  separates  it  from  the  limbic  region  ; and  behind  by  the 
ascending  branch  of  the  calloso  - marginal  sulcus,  called  also  the 
subparietal  branch  {ramus  suhparietalis). 

For  morphological  and  embryological  reasons,  the  limho-hippo- 


campic  region  is  considered  in  its  entirety,  not  divided  into  the 
three  usual  convolutions,  the  corpus  callosum  or  gyrus  fornicatus, 
the  precuneus  and  the  hippocampus.  From  the  point  of  view  of 
this  work  it  is  useful  to  consider  this  region  as  a whole.  Commencing 
as  the  convolution  of  the  corpus  callosum  {gyrus  fornicatus,  gyrus 
cinguli)  underneath  the  genu,  it  follows  very  precisely  the  curve  of 
the  genu,  being  separated  from  it  by  the  sulcus  of  the  corpus  callosum 
and  from  the  frontal  gyrus  by  the  calloso-marginal  sulcus  {sulcus 
cinguli)  ; after  rounding  the  genu  it  is  directed  almost  horizontally 
backwards,  forming  the  central  part  of  the  gyrus  fornicatus.  At 
that  point  in  its  course  corresponding  exactly  to  the  posterior 
part  of  the  corpus  callosum  and  its  splenium,  it  widens  out  into  the 
quadrate  lobule  or  precuneus  {prcecuneus),  this  being  well  delimited 
in  front  by  the  ascending  branch  of  the  calloso-marginal  sulcus 
(subparietal  branch  of  the  sulcus  cinguli),  behind  by  the  occipito- 


30 


PSYCHIATRY 


parietal  fissure  Ifissura  parietalis  occipitalis),  above  by  the  inter- 
hemispheric  margin,  while  below  it  is  prolonged  into  the  descending 
branch  of  the  limbic  convolution.  The  latter  is  continued  without 
interruption  into  the  convolution  of  the  hippocampus  {gyrus  hippo- 
campi), This  convolution  in  turn  forms  the  central  region  of  the 
hemisphere,  and  results  from  the  fusion  of  the  part  of  the  limbic 
convolution  just  described,  and  the  lingual  convolution  or  lobule 
belonging  to  the  occipital  lobe  {gyrus  lingualis ; vide  Fig.  7).  It  is 
prolonged  almost  horizontally  in  front,  describing  a slight  curve 
with  its  convexity  downwards,  and  after  reaching  the  fissure  of 
Sylvius  recurves  upwards  and  inwards,  forming  the  uncus  or  crotchet, 
or,  as  some  anatomists  term  it,  the  uncinate  convolution  {uncus). 

Occipital  Region. — The  precuneus  or  quadrate  lobe,  as  alread}^ 
mentioned,  is  separated  from  the  occipital  lobe  behind  by  the 
occipito-parietal  fissure,  usually  very  deep  and  prolonged  downwards 
and  forwards  to  meet  the  calcarine  fissure  (Fig.  7).  The  latter  is 
in  turn  prolonged  to  the  point  where  the  descending  branch  of  the 
quadrate  lobule  of  the  limbic  convolution  unites  with  the  lingual 
lobule— which  lies  under  the  calcarine  fissure — so  as  to  form  the 
convolution  of  the  hippocampus. 

As  the  calcarine  fissure  is  almost  horizontal  in  its  posterior  part, 
while  the  parieto-occipital  fissure  is  oblique  from  above  downwards 
and  forwards,  separating  distinctly  the  limbic  from  the  occipital 
lobe,  the  result  is  that  a triangular  portion  of  this  internal  occipital 
surface  of  the  hemisphere,  always  easily  recognisable,  is  enclosed 
between  these  two  fissures.  This  portion,  on  account  of  its  form,  is 
termed  the  cuneus. 

As  shown  in  Fig.  7,  what  remains  of  the  occipital  lobe  under- 
neath the  calcarine  fissure  is  divisible  into  two  convolutions — 
the  superior,  already  indicated,  is  called  the  lingual  lohule  or  con- 
volution {gyrus  lingualis),  and  extends  forwards  from  the  inter- 
hemispheric  border  in  a slightly  curved  form,  to  meet  the  limbic 
convolution,  becoming  continuous  with  the  hippocampus , the 
inferior,  called  the  occipito-temporal  convolution  or  fusiform  lobule 
{gyrus  fusiformis),  runs  in  the  same  direction  as  the  former,  but  is 
more  straight  and  horizontal,  and  fuses  in  front  with  the  convolu- 
tions of  the  temporal  lobe.  These  last  two  convolutions  are  sepa- 
rated for  a considerable  distance  by  the  occipito-temporal  sulcus. 


Inferior  Aspect  of  the  Cerebral  Hemisphere 

The  inferior  aspect  of  the  hemisphere  may  be  roughly  distin- 
guished into  two  regions — the  frontal  or  pre-Sylvian,  and  a more 
extensive  one,  the  temporo-occipital  01  post-Syl\  ian  these  being 
separated  distinctly  by  the  fissure  of  Sylvius.  Ihe  first,  as  a whole, 
is  the  continuation  on  the  inferior  or  orbital  aspect  of  the  hemi- 
sphere of  the  three  frontal  convolutions  of  the  external  aspect. 


ANATOMICAL  SKETCH  OF  CEREBRAL  MANTLE  31 


The  innermost  (called  also  the  straight  convolution)  of  the  three  con- 
volutions thus  formed  is  the  continuation  of  the  superior  frontal  con- 
volution, and  is  indented  by  the  furrow  in  which  lies  the  olfactory 
lobule  ; the  middle  is  a continuation  of  the  middle  frontal,  and  the 
outermost  is  part  and  parcel  of  the  inferior  frontal  convolution. 
The  three  convolutions  are  practically  separated  by  the  olfactory 
sulcus  {sulcus  olfactorius)  and  the  orbital  sulcus  (sulcus  orhitalis). 

The  occipito-temporal  portion  is  composed  of  three  convolu 


Fig.  8. — Inferior  Aspect  of  the  Hemispheres. 


tions — the  outermost  is  the  inferior  face  of  the  third  temporal 
convolution,  seen  on  the  external  aspect  of  the  hemisphere  (inferior 
or  third  temporal  convolution,  gyrus  temporalis  inferior) ; the  middle 
goes  by  the  name  of  the  occipito-temporal  convolution  or  fusiform 
lobule  i^gyrus  fusiformus) ; whilst  the  innermost  is  the  hippocampus 
l^gyrus  hippocampi). 

Two  sulci  separate  these  convolutions  from  one  another — the 
inferior  temporal  sulcus  (^sulcus  temporalis  inferior)  and  the  occipito- 
temporal or  collateral  sulcus  ijissura  collator alis). 

For  our  purposes  it  is  useless  to  enter  into  fuller  details,  which 


32 


PSYCHIATRY 


may  be  obtained  by  consulting  numerous  modern  works  on  the 
anatomy  of  the  brain.  A few  further  details,  however,  will  be  dis- 
cussed at  a subsequent  stage  of  the  work,  the  aim  of  which,  at  this 
particular  point,  is  to  indicate  merely  the  general  features  of  the 
architecture  of  the  brain,  so  as  to  render  these  clear  and  intelli- 
gible in  such  applications  of  them  to  physiology  and  psychology 
as  we  shall  make  in  accoi dance  with  the  practical  nature  and  limits 
of  this  work.  The  anatomical  provinces,  as  we  have  described 
them,  do  not,  however,  coincide  with  the  physiological.  On  the 
contrary,  the  anatomy  of  the  paths  of  projection  and  of  association 
indicates  a distribution  of  function  quite  different  in  its  localiza- 
tions to  that  of  the  convolutions  and  lobes  on  all  aspects  of  the 
hemisphere.  I consider  it  very  useful  in  this  connection  to  describe 
briefly  such  facts  as  the  most  recent  anatomical  researches  have 
brought  to  light  and  established  beyond  all  doubt.  These  we  will 
compare  with  the  results  demonstrated  by  physiological  researches 
and  with  the  synthesis  of  clinical  observation,  with  the  ultimate 
object  of  showing  how  much  at  the  present  day  is  founded  upon 
the  distribution  of  the  functions  of  the  cerebral  cortex.  Let  us 
begin  by  following  the  course  of  the  central  paths  in  the  case  of  the 
olfactory  nerves. 

Olfactory  Paths  and  Centres 

The  olfactory  nervous  apparatus  commences  with  the  proto- 
plasmic processes  of  the  bipolar  cells  situated  among  the  epithelial 
cells  of  the  olfactory  mucous  membrane.  These  bipolar  cells  with 
large  nuclei  constitute  the  first  station  of  the  olfactory  wave,  which 
is  received  by  the  external  or  peripheral  process  of  a given  cell 
and  transmitted  by  the  internal  or  axis-cylinder  process  (Fig.  9) 
(Schultze,  Grassi  and  Castronuovo,  Cajal).  These  centripetal 
processes  collected  together  form  the  true  olfactory  nerve,  and  end 
in  the  olfactory  bulb.  The  latter  is  a true  cerebral  lobe,  and  is, 
in  fact,  composed  of  several  strata  of  nerve  elements,  the  most 
important  being  : 

The  zone  of  the  glomeruli,  which  are  nothing  else  than  the  points  of 
junction  of  the  axis-cylinder  processes  of  the  bipolar  cells  of  the  nasal 
mucous  membrane,  with  the  protoplasmic  processes  of  the  mitral 
cells  of  the  innermost  stratum  (fourth  stratum  of  some  authors). 

The  two  processes  (one  from  a bipolar  cell,  the  other  from  a 
mitral  cell),  meeting  together,  form  with  their  arborizations  numer- 
ous twistings,  from  the  sum  of  which  the  glomerulus  results  (I  leave 
unprejudiced  the  question  whether  the  said  processes  merely  come 
into  contact,  or,  in  other  words,  terminate  freely,  as  held  by  Van 
Gehuchten,  Retzius,  Kolliker,  and  the  brothers  CajaJ,  or  whether 
they  form  a reticulum,  as  maintained  by  Golgi  and  the  numerous 
researches  of  Apaty  and  others). 


OLFACTORY  PATHS  AND  CENTRES 


33 


I The  olfactory  wave,  then,  having  traversed  the  protoplasmic 
process  of  the  bipolar  cell,  the  centripetal  arborization  of  which 
I enters  into  the  formation  of  the  glomerulus,  is  transmitted  to  the 
1 small  nerve  cells  of  the  molecular  layer  and  to  the  mitral  cells — large 
' triangular  or  mitre-shaped  cells  (fourth  layer  of  some  histologists), 
j These  cells  in  turn  transmit  it  by  means  of  their  axis-cylinder  pro- 
j cesses,  which  go  to  form  the  white  substance  of  the  bulb,  their  col- 
i laterals  distributing  themselves  in  the  zone  of  the  granules  and  of 
the  myelinated  fibres  composing  the  fifth  layer  of  the  olfactory 


Fig.  9. — Scheme  of  the  Olfactory  Apparatus  in  Mammals. 

A,  Olfactory  lobe  ; B,  olfactory  bulb  ; C,  cartilage  of  the  lamina  cribrosa  in  the 
embryo  ; D,  nasal  mucosa  ; a,  supporting  cell  ; b,  olfactory  bipolar  cell  ; c,  arboriza- 
tion of  an  olfactory  fibre  in  the  substance  of  the  glomerulus  ; d,  small  cell  with  basket 
work,  and  i,  its  axis  cylinder  process  ; e,  mitral  cell  ; h,  granules  ; g,  large  stellate 
cell,  the  short  axis  cylinder  of  which — f — terminates  in  the  molecular  layer  ; 
j,  arborization  of  fibres  of  central  origin  ; k,  1,  contacts  between  the  arborizations 
of  the  central  fibres  and  those  of  the  axis-cylinder  processes  of  the  mitral  cells. 

bulb.  From  the  axis-cylinder  processes  of  the  cells  of  the  granular 
layer  and  of  the  mitral  cells  the  olfactory  wave  passes  along  the 
fibres  of  the  olfactory  tract  and  reaches  the  brain. 

Fig.  10  indicates  even  more  clearly  the  course  of  the  olfactory 
vave. 

, The  olfactory  tract,  lying  with  its  upper  border  in  the  olfactory 
mlcus  formed  internally  by  the  straight  convolution  of  the  frontal 
'obe,  and  externally  by  the  orbital  part  of  the  first  frontal  convolu- 
ion,  extends  from  before  backwards  to  near  the  anterior  perforated 
.pot.  It  forms  the  so-called  olfactory  tubercle  or  trigone,  and 

' 3 


34  PSYCHIATRY 

divides  into  two  branches  or  roots  (according  to  others  into  three), 
an  external  and  an  internal  (vide  Fig.  8).  In  some  cases  a very 
delicate  middle  branch  can  be  distinctly  made  out,  but  not  infre- 
quently it  is  absent. 

The  external  branch  can  be  traced  as  far  as  the  uncinate  con- 
volution, giving  off  fibres,  according  to  some  authorities,  to  the 
nucleus  of  the  amygdala,  and  other  branches  to  the  inner  part  of  the 
temporal  lobe  and  the  hippocampus. 

The  other  branch,  called  also  the  internal  white  root,  buries  itself 
in  the  perforated  substance,  and  is  directed  inwards  and  upwards. 
The  further  source  of  the  fibres  in  this  root  is  still  obscure.  ^ Ober- 
steiner  believes  that  they  run  to  the  sides  of  the  corpus  striatum, 
and  assume  relations  also  with  a number  of  large  fusiform  gan- 
glionic cells  which  he  refers  to  the  central  olfactory  apparatus. 


A,  Olfactory  mucosa  ; B,  olfactory  glomerulus  of  the  bulb  ; C,  mitral  cells ; ' 
E,  granules  ; D,  olfactory  tract  ; G,  region  of  the  external  white  root  of  the  olfactory  ‘ 
nerve  ; F,  pyramidal  cells  of  the  tract  ; M,  cells  with  short  axis  cylinder  ; j,  col- 
laterals of  the  axis  cylinders  of  the  mitral  cells  at  the  level  of  the  olfactory  bulb  ; 
H,  collaterals  of  these  same  axis  cylinders  in  the  tracts  ; L,  centrifugal  fibres.  (From 
R.  Cajal.)  il 

( 

Another  bundle  from  this  same  root,  turning  upwards  and  in-| 
wards,  would  seem  to  diffuse  itself  partly  in  the  anterior  section  of  *| 
the  gyrus  fornicatus,  and  partly  (according  to  others)  in  the  posterior 
section.  According  to  Dejerine,  this  root  loses  itself  in  the  olfactory'- 
carrefour  of  Broca,  formed  by  the  first  frontal,  where  it  fuses  with 
the  limbic  convolution  (Fig.  7).  Before  the  olfactor}^  tract  divides 
into  the  branches  or  roots  above  indicated,  it  supplies  twigs  to  the 
gray  substance  of  the  olfactory  sulcus  in  which  it  is  embedded  (part 
of  these  fibres  form  the  superior  olfactory  root  of  Broca).  I have 
been  able  to  follow  some  of  those  fibres  in  vertical  sections  of  the 
brains  of  monkeys  almost  up  to  the  anterior  peduncle  of  the  trigone 
(Weigert’s  coloration). 

Another  bundle,  little  developed  in  man  and  monkeys,  but  very, 
marked  in  keen-scented  animals,  would  seem  to  be  directed  towards' 
the  anterior  commissure.  From  this  bundle  fibres  going  to  the, 


OLFACTORY  PATHS  AND  CENTRES 


35 


anterior  part  of  the  optic  thalamus  are  given  off.  This  olfactory 
part  of  the  anterior  commissure  contains  both  commissural  fibres 
uniting  the  two  olfactory  lobes,  and  others  which,  after  crossing  the 
median  line,  unite  the  olfactory  lobe  of  one  side  with  the  temporal 
lobe  of  the  opposite. 

In  order  to  complete  the  summary  of  the  olfactory  system,  it  will 
be  sufficient  to  describe  the  diagonal  tracts  of  Broca  which  detach 
themselves  from  each  side  of  the  beak  of  the  corpus  callosum,  in 
front  of  which  they  diverge,  proceeding  obliquely  outwards  and 
backwards.  In  this  way  they  cross  diagonally  the  anterior  per- 
forated space,  directing  themselves  towards  the  adjacent  border  of 
the  temporo-sphenoidal  lobe.  These  fibres  are  formed  partly  by 


Fig.  II. — Vertical  Section  of  the  Brain  at  the  Level  of  the  Anterior 

Commissure. 

the  nerves  of  Lancisi,  which,  classed  among  the  rudimentary  convolu- 
tions, should  be  considered  as  the  continuation  of  the  fascia  dentata. 

The  olfactory  radiations  pass  through  a layer  of  white  fibres, 
found  between  the  layer  of  gray  matter  covering  the  anterior  per- 
forated spot  and  the  globus  pallidus  (second  and  third  segment  of 
the  lenticular  nucleus).  This  explains  how  it  is  that  extensive  lesions 
of  the  posterior  part  of  the  internal  capsule  can  produce  alterations 
of  the  sense  of  smell.  The  anterior  commissure  also  is  formed  in  man 
by  a stout  bundle  of  nerve  fibres  passing  through  the  posterior  part 
of  the  internal  capsule,  and  serving  for  the  rnost  part  to  establish 
an  ample  association  between  the  temporal  lobes,  and  especially 

3—2 


PSYCHIATRY 


36 

between  the  hippocampi  on  either  side,  and  perhaps  also  between  the 
occipital  lobes  and  between  the  nuclei-amygdalarum  (Fig.  ii)  ; it 
is  accordingly  supplementary  to  the  corpus  callosum. 

The  true  origin  of  its  fibres,  however,  is  still  unknown.  One  case 
recorded  by  Popof  and  another  by  Flechsig  pointed  to  the  belief 
that  it  constituted  a commissure  between  the  two  lingual  lobes  and 
the  fusiform  convolutions.  The  cases  of  Henschen  and  the  observa- 
tions of  Dejerine  contradict  this  theory.  Further  and  more  accurate 
observations  are  requisite  for  the  solution  of  this  anatomical  problem. 

There  is,  however,  an  olfactory  part  of  the  anterior  commissure, 
very  scant  in  man,  but  pronounced  in  keen-scented  animals,  com- 
posed of  fibres  passing~at  least,  in  part— from  the  cortex  of  the 
olfactory  lobe  to  the  homonymous  cortex  of  the  other  side.  If  this 
is  the  case,  one  cannot  compare  the  anterior  commissure  to  the  optic 
chiasma,  because  it  is  not  the  fibres  of  the  olfactory  nerves  that  cross 
in  the  anterior  commissure. 

Meynert’s  hypothesis  of  a decussation  of  the  olfactory  tracts  in 
the  anterior  commissure  is  contradicted  by  the  observations  of 
Gudden  and  Ganser.  In  conclusion,  we  may  consider  it  demon- 
strated that  the  anterior  commissure  contains  a so-called  olfactory 
part  (improperly  called  olfactory  chiasma),  with  fibres  which  cross 
and  put  the  two  olfactory  bulbs  in  interrelation,  and  fibres  crossing 
in  the  median  line  to  unite  the  olfactory  lobe  of  one  side  with  the 
temporal  lobe  of  the  other  (Dejerine).  There  is,  moreover,  the  com- 
missural part  of  which  v/e  have  already  spoken. 

In  some  mammals  there  is  an  ascending  branch  of  the  anterior 
commissure,  which  passes  into  the  external  capsule  and  unites  the 
dorsal  parts  of  the  limbic  lobes  of  both  sides  (Edinger). 

Experiments  on  the  olfactory  cortical  centres  have  also  yielded 
somewhat  uncertain  results,  and  show  that  these  are  situated  on 
the  hemisphere  of  the  same  side.  While  some  clinical  cases,  such  as 
those  of  Ogle,  Flechner,  and  Ransome,  demonstrate  that  anosmia  is 
found  in  the  nostril  opposite  to  the  paralyzed  side — i.e.,  homonymous 
with  the  injured  hemisphere — other  cases  in  which  hemianosmia  is 
found  on  the  same  side  as  the  paralysis — i.e.,  on  the  side  opposite  to 
the  injured  hemisphere — can  probably  be  interpreted  as  resulting 
from  defect  of  tactile  sensation  on  the  paralyzed  side,  it  being  well 
known  that  the  aiicesthesia  following  a lesion  of  the  trigeminus  pro- 
duces disturbances  of  smell  (Magendie  and  others). 

So  far,  it  is  clear  that  the  fibres  which  pass  by  means  of  the 
anterior  commissure  from  the  olfactory  bulb  of  one  side  to  the  tem- 
poral lobe  of  the  other  could  explain  the  hemianosmia,  possibly 
temporary,  observed  in  some  cases,  on  the  side  opposite  to  the  lesion, 
when  the  previous  interpretation  affords  no  solution,  because  it  is 
well  known  that  the  number  of  these  fibres,  as  also  the  formation  of 
the  nerves  of  Lancisi  and  the  diagonal  tract,  vary  very  much  in 
different  individuals. 


OLFACTORY  PATHS  AND  CENTRES 


37 


Fig.  12,  taken  from  Obersteiner’s  work,  shows  quite  clearly  the 
distribution  of  the  fibres  of  the  olfactory  tract  in  accordance  with 
the  present  state  of  our  knowledge.  It  assists  also  in  removing  the 
contradictions  of  individual  observers. 

If  Ferrier  maintains  that  the  centre  of  smell  is  the  uncinate 
gyrus,  and  Schafer,  on  the  contrary,  holds  with  equal  reason  that  a 
marked  disturbance  of  smell  is  produced  by  destruction  of  the 
anterior  part  of  the  limbic  lobe,  and  others,  again,  by  destruction  of 
the  posterior  part — a fact  which  has  been  fully  confirmed  by  the 
experiments  of  Dr.  Sacconi  carried  out  in  my  institute — this  is  due 
to  the  fact  that  the  whole  limbic  lobe  and  the  corpus  dentatum  must 
be  considered  as  the  cortical  centre,  not  merely  the  olfactory  carrefour 
and  the  anterior  perforated  substance.  It  appears  that  we  must 
also  retain  the  trigone  and  the  septum  lucidum  as  olfactory  paths. 
Whether  the  bundle  of  Vicq  D’Azir,  going  from  the  mammillary 


57 


BO,  Olfactory  bulb  ; lO,  olfactory  tract  ; P,  membrane  of  Schneider; 
cto,  cortex  of  the  olfactory  tract  ; cc,  cerebral  cortex  ; g,  central  ganglion  ; 
ca,  anterior  commissure  ; 5,  olfactory  part,  and  7,  hemispheric  part  of  the  anterior 
commissure.  (Obersteiner.) 

body  to  the  anterior  nucleus  of  the  optic  thalamus,  is  also  an  olfactory 
j)ath,  inasmuch  as  tlie  mammillary  body  receives  the  anterior 
peduncle  of  tlie  trigone,  is  a point  which  only  further  researches  will 
either  confirm  or  disprove. 

This  much  is  certain,  that  in  the  formation  of  the  olfactory 
system  (rhinencephalon)  there  also  take  part  the  dentate  convolu- 
tion and  its  prolongations  on  the  surface  of  the  corpus  callosum  in 
the  form  of  the  nerves  of  Lancisi,  and  that  the  cornu  ammonis,  the 
gyrus  fornicatus,  and  the  corpus  dentatum,  all  highly  developed  in 
keen-scented  amimals,  ought  to  be  considered  as  cortical  organs 
connected  with  the  function  of  smell.  In  recent  times  Retzius  has 
regarded  the  anterior  perforated  substance  '{gyrus  perforatus  rhin- 
cnccphali)  and  the  gray  substance  surrounding  the  olfactory  tubercle 
as  also  forming  part  of  the  rhinencephalon. 


38 


PSYCHIATRY 


Optic  Paths  and  Centres 

The  luminous  waves  are  received  by  the  retinal  rods  and  cones, 
which  should  be  considered  as  the  modified  free  extremities  of  the 
protoplasmic  processes  of  the  nerve-cell  corpuscles  of  the  retina. 
The  different  forms  of  the  rods  and  cones,  and  the  difference  between 
the  cell  elements  from  which  they  originate  should  lead  to  the  con- 
clusion that  they  must  receive  different  luminous  waves  ; according 
to  some,  the  rods  would  serve  for  the  reception  of  uncoloured  light, 
the  cones  for  coloured  light.  Both  rods  and  cones  are  in  relation 
with  cell  bodies  of  different  form  and  situated  at  different  distances 


Fig.  13. 

A,  Layer  of  the  rods  and  cones  ; B,  bodies  of  the  visual  cells  (external  granules)  ; 
C,  external  plexiform  layer  ; E,  layer  of  the  bipolar  cells  (internal  granules)  ; 
F,  internal  plexiform  layer  ; G,  layer  of  the  ganglion  cells  ; H,  layer  of  the  fibres 
of  the  optic  nerve  ; a,  rod  ; b,  cone  ; c,  cell-body  of  the  cone  ; d,  cell-body  of  the 
rod  ; e,  bipolar  cell  for  the  rod  ; fffff,  bipolar  cells  for  the  cones  ; ghijk,  ganglion 
cells  ramifying  at  various  levels  of  the  internal  plexiform  layer  ; r,  inferior  arboriza- 
tion of  the  bipolar  cells  for  the  cones  ; t,  cell  of  Mueller,  or  epithelial  cell  ; x,  con- 
tacts between  the  rods  and  the  bipolar  cells  ; z,  contact  between  the  cones  and  the 
bipolar  cells  ; s,  centrifugal  nerve  fibres. 


— those  of  the  cones  in  proximity  to  the  cones,  those  of  the  rods  at 
a greater  distance  (Fig.  13).  Where  the  axis-cylinder  processes  of 
the  cells  of  the  rods  and  cones  meet  with  the  expansions  of  the  proto- 
plasmic processes  of  the  underlying  layer  of  cells,  there  occurs  an 
interlacement  of  arborizations,  to  which  has  been  assigned  the  name 
of  external  plexiform  layer.  These  protoplasmic  expansions  found 
here  belong  to  the  succeeding  layer,  which  is  composed  of  bipolar 
and  other  cell  forms  (horizontal,  stellate),  constituting  a second  order 
of  retinal  cell  corpuscles— the  internal  granular  layer. 

These  latter  cells  transmit  the  waves  by  their  axis-cylinder  pro- 
longations to  a third  order — the  so-called  ganglionic  cells.  Between 
these  two  layers  of  cells,  however,  there  is  another  layer  formed  by  the 


OPTIC  PATHS  AND  CENTRES 


39 


axis-cylinder  prolongations,  from  the  internal  granular  layer  meeting 
and  interlacing  with  the  protoplasmic  processes  of  the  various 
cell  forms  situated  more  externally — the  internal  plexiform  layer. 

It  is  the  axis-cylinder  processes  of  the  ganglionic  cells  that  form 
the  fibres  of  the  optic  nerve. 

This  diagrammatic  description  of  the  nerve  elements  of  the 
retina  helps  us  to  understand  the  course  of  the  luminous  waves,  and 
it  is  well  to  bear  in  mind  that  various  forms  of  cell  corpuscles  are 
found  in  the  different  retinal  layers.  Among  these,  I must  not  neglect 
to  mention  the  so-called  spongioblasts,  found  more  or  less  at  all  levels 
of  the  internal  granular  layer,  but  in  greatest  number  in  the  deepest 
zone.  These  cells  present  the  peculiarity  of  not  possessing  axis- 
cylinder  processes,  but  only  a rich  expansion  of  protoplasmic  pro- 
cesses which  come  into  contact  with  axis-cylinder  processes  and 
collaterals  belonging  to  other  types  of  retinal  nerve  cells  (the  bipolar, 


A,  Retina  ; B,  optic  nerve  ; a,  cone  ; b,  rod  ; d,  bipolar  cell  for  the  cone  ; c,  bipolar 
cell  for  the  rod  ; e,  ganglion  cell  ; f,  centrifugal  nerve  fibre  ; g,  spongioblast  ; h,  free 
arborization  of  fibres  coming  from  the  retina  ; j,  nerve  cell,  the  protoplasmic  expan- 
sion of  which  serves  to  receive  the  excitation  transmitted  by  the  optic  fibres  ; r,  cell 
from  which  the  centrifugal  fibre  probably  arises.  (From  R.  y Cajal.) 

the  ganglionic),  and  also  with  the  centrifugal  fibres  which  are  sup- 
posed to  be  concerned  in  the  conduction  of  nerve  waves  from  the 
centres  to  the  ganglionic  cells  (centrifugal  optic  paths).  Such  cell 
elements  have  the  credit  of  establishing  associative  relations  between 
nerve  elements  of  varying  form  and  physiological  significance. 
Besides  the  spongioblasts,  however,  there  also  exist  collaterals  of 
the  nerve  prolongations,  as  well  as  protoplasmic  collaterals,  thus 
making  the  function  of  the  retina  much  more  complicated  than 
would  appear  from  this  schematic  description.  The  accompanying 
diagram  renders  much  more  intelligible  the  most  probable  course 
of  the  luminous  rays  (Fig.  14). 

The  optic  nerves,  according  to  some,  are  formed  from  those  short 
fibres  running  between  the  rods  and  cones  and  the  respective  nerve 
cells  found  in  the  retina.  When,  however,  one  considers  the  rela- 
tively small  proportion  of  retinal  nerve  cells,  in  comparison  with  the 
number  of  fibres  in  the  optic  nerve,  this  presumption  can  only  in  part 
be  justified. 


40 


PSYCHIATRY 


The  optic  nerves,  as  all  anatomists  regard  them,  may  be  con- 
sidered as  composed  of  two  bundles,  of  which  one — the  external — 
passes  into  the  optic  tract  of  the  same  side,  and  the  other — internal — 
decussates  with  the  internal  bundle  of  the  optic  nerve  of  the  other 
side,  to  form  the  chiasma.  This  is  composed  of  different  orders  of 
hbres  : 

1.  Uncrossed  fibres  situated  at  the  outer  border  of  the  chiasma  : 
these  come  from  the  outer  half  of  the  retina  and  pass  to  the  tract 
on  the  same  side. 

2.  Fibres  coming  from  the  inner  half  of  the  retina  : these  decus- 
sate, in  the  chiasma,  with  the  corresponding  fibres  of  the  other  side 
and  pass  to  the  optic  tract  on  the  opposite  side. 

3.  Fibres  going  from  one  optic  tract  to  the  other,  passing  through 
the  posterior  angle  of  the  chiasma.  This  is  the  inferior  commissure 
of  Gudden,  which,  strictly  speaking,  should  not  form  a part  of  the 
optic  nerves. 

4.  By  some  there  is  described  an  anterior  commissure  of  the 
chiasma,  formed  of  fibres  establishing  relations  between  the  two 
retinae. 

5.  The  commissure  of  Meynert,  composed  of  fibres  originating 
from  the  large  pigmented  cells  found  in  the  tuber  cinereum.  At  that 
part  of  the  anterior  perforated  substance  overlying  the  optic  tract 
these  fibres  decussate  at  an  acute  angle,  right  above  the  chiasma, 
and  pass  into  the  tract.  They  appear  to  terminate  in  the  sub- 
thalamic substance. 

The  optic  tract,  before  reaching  the  optic  thalamus,  to  which  it 
is  directed,  divides  into  two  branches  or  roots — one  external  and 
the  other  internal. 

The  external  root  appears  to  merge  as  a whole  into  the  external 
geniculate  body,  but  in  reality  gives  off  three  important  bundles  of 
fibres  ; one  goes  to  form  a part  of  the  external  geniculate  body, 
another  reaches  the  pulvinar,  and  the  third  arrives  at  the  anterior 
quadrigeminate  body,  passing  through  the  peduncle  of  the  latter. 

Some  other  fibres  of  this  root  go  to  constitute  the  stratum 
zonale  of  the  optic  thalamus.  The  three  ganglionic  masses  above 
indicated  are,  as  it  were,  three  intermediate  stations  on  the  external 
branch  of  the  optic  tract  ; from  them  issue  paths  (optic  fibres) 
which  reach  the  post  and  subthalamic  parts  of  the  capsule,  and 
proceed  to  form  the  sensory  bundle  situated  at  the  outside  of  the 
posterior  horn  of  the  lateral  ventricle  and  the  tapetum,  and  forming 
the  principal  optic  path  to  the  cortex  of  the  occipital  lobe. 
(Wernicke,  Brissaud,  Dejerine,  Vialet,  Henschen,  and  others.) 

The  internal  root  can  be  followed  as  far  as  the  internal  geniculate 
nucleus. 

Obersteiner  holds  that  many  fibres  of  the  internal  root  penetrate 
the  internal  geniculate  ganglion,  while  some  would  seem  to  pass  to 
the  anterior  and  others  to  the  posterior  corpus  quadrigeminus. 


OPTIC  PATHS  AND  CENTRES 


41 


The  researches  of  Monakow  and  Coined,  however,  have  demon- 
strated that  no  atrophy  is  found  in  the  internal  geniculate  ganglion 
consequent  upon  enucleation  of  the  eyes,  while  it  is  observed  in 
the  external  geniculate  body.  Monakow  furnishes  clear  evidence 
that  the  fibres  of  the  internal  geniculate  body  and  of  the  posterior 
quadrigeminate  body  are  in  connection  with  the  temporal  lobe,  and 
that  accordingly  the  posterior  quadrigeminate  and  the  internal 
geniculate  bodies  ought  to  be  regarded  as  intermediate  acoustic 
paths  and  stations. 


Fig.  15. — Scheme  of  the  Course  of  the  Optic  Paths  from  the  Retina  to  the 

Cortex. 

R,  Retina,  the  external  half  of  which  corresponds  to  the  hemisphere  of  the  same 
side,  the  internal  half  being  related  to  the  opposite  hemisphere  ; No,  optic  nerve  ; 
Ch,  chiasma  ; Tro,  optic  tract,  or  bandelette  ; CM,  commissure  of  Meynert  ; 
CG,  commissure  of  Gudden  ; 1,  lateral  root  ; m,  median  root  of  the  tract  ; Tho,  optic 
thalamus  ; Cgl,  lateral  geniculate  body  ; Qa,  corpora  quadrigemina  ; Bga,  bra- 
chiuni  of  the  anterior  quadrigeminate  body  ; Rd,  direct  cortical  root  of  the  tract  ; 
Ss,  subcortical  optic  radiations  ; Co,  visual  cortex  ; Lm,  lemniscus. 

It  is  not  improbable,  then,  that  the  internal  root  is  constituted 
in  part  by  the  fibres  of  the  inferior  commissure  of  Gudden  and  that 
of  Meynert. 

In  all  probability  the  majority  of  the  fibres  of  the  internal  root 
pass  into  the  optic  thalamus. 

Besides  the  given  paths  of  the  tract,  there  are  still  others. 
Among  these  we  must  mention  {a)  the  superficial  or  middle  root 
(Stilling),  which,  passing  between  the  geniculate  bodies,  proceeds 


42 


PSYCHIATRY 


directly  to  the  anterior  quadrigeminate  eminence ; (b)  the  deep 
root  of  the  tract,  composed  of  fibres  which  reach  the  cerebral 
peduncle,  accumulate  on  the  outer  part  of  the  pes,  and  project 
themselves,  as  direct  radiations,  into  the  white  substance  of  the 
hemisphere,  where  they  pursue  a course  along  with  the  longitudinal 
medullary  bundle  of  Wernicke,  towards  the  occipital  lobe.  This 
root  is  the  so-called  direct  hemispheric  bundle  of  Gudden.  Some  of 
these  fibres  descend  in  the  cerebral  peduncle,  and  seem  to  have 
been  followed  by  Stilling  to  the  level  of  the  decussation  of  the 
pyramids  (Obersteiner).  (c)  Fibres  going  directly  from  the  chiasma 
to  the  gray  substance  of  the  third  ventricle  (basal  root  of  the  optic 
nerve),  (d)  According  to  Darkschewitsch,  the  oculo-motor  nerve 
would  also  seem  to  get  from  the  optic  tract  a small  bundle,  which, 
after  leaving  the  external  geniculate  body,  would  appear  to  proceed 
through  the  optic  thalamus  to  the  pineal  gland  and  the  pedunculus 
conarii,  and  from  this  latter  to  the  oculo-motor  nerve,  by  means  of 
the  ventral  part  of  the  posterior  commissure. 

From  the  three  principal  ganglionic  masses  of  the  optic  tract — 
the  external  geniculate  body,  the  optic  thalamus,  and  the  anterior 
quadrigeminate  body — there  issue  ganglio-cortical  fibres  constitut- 
ing the  so-called  optic  radiations  going  to  the  cerebral  cortex. 

They  form  what  Vialet  calls  the  bundle  of  the  visual  fibres,  or 
layer  of  the  optic  radiations,  which,  by  describing  a course  closely 
following  the  tapetum,  makes  a circuit  of  the  ventricle  by  a some- 
what spiral  course  along  the  external  side,  diminishing  in  volume 
in  proportion  as  it  approaches  the  cortex,  where  it  expands  on  the 
internal  aspect  of  the  occipital  lobe  and  pole.  Along  this  course 
the  cortical  optic  fibres  mingle  with  the  fibres  of  projection  of  the 
temporal  and  parietal  lobes  and  other  associated  bundles,  with  which 
they  decussate  at  a more  or  less  acute  angle.  Fig.  15,  taken  from 
Obersteiner,  shows  some  of  the  most  assured  relations  mentioned 
above.  It  is  well  to  add,  however,  that  many  do  not  admit  the 
existence  of  the  direct  cortical  root  of  the  tract. 

At  this  point  we  may  be  permitted  to  make  a slight  digression, 
in  order  to  clear  the  way  for  what  we  have  to  say  subsequently. 

Brissaud  does  not  agree  with  Vialet  in  the  distribution  of  the 
optic  radiations  and  the  signification  of  the  inferior  longitudinal 
bundle.  He  distinguishes  three  layers  of  fibres  in  the  large  antero- 
posterior white  mass  of  the  occipital  lobe  : (i)  The  tapetum,  (2)  the 
internal  sensory  bundle,  (3)  the  external  sensory  bundle. 

Vialet  admits  that  only  the  second  of  the  above-mentioned 
bundles  comprises  the  optic  radiations,  and  that  the  third — i.e.,  the 
external  sensory  bundle — may  constitute  a system  of  association 
with  a long  endo-hemispheric  course,  and  may  therefore  represent 
the  inferior  longitudinal  bundle  ; while  Brissaud  holds  that  the 
external  bundle  contributes  to  the  formation,  but  is  not  the  sole 
constituent,  of  the  inferior  longitudinal  bundle.  In  fact,  it  contains 


OPTIC  PATHS  AND  CENTRES 


43 


many  fibres  of  radiations  coming  from  the  corona  radiata  of  the  optic 
thalamus  and  from  the  second  and  third  segment  of  the  lenticular 
nucleus.  It  would  thus  be  largely  a projection  bundle.  In  a later 
work  of  Vialet  the  statements  of  Brissaud  are,  in  the  main,  accepted  ; 
for  he  concludes  that  the  inferior  longitudinal  bundle  (or  external 
sensory  bundle)  is  composed  of  various  fibres,  the  majority  of  them 
terminating  in  the  temporal  lobe  (associative  fibres),  while  some  go 
to  join  with  the  fibres  of  the  corona  radiata  of  the  optic  thalamus, 
and  others  to  the  external  capsule  and  the  second  and  third  segments 
of  the  lenticular  nucleus. 

We  come  now  to  the  question  of  the  whereabouts  of  the  cortical 
visual  area. 

In  recent  years  the  knowledge  derived  from  a closer  observation 
of  clinical  facts  has  quite  revolutionized  the  original  doctrines  of 
Ferrier,  Munk,  and  many  others  who  had  looked  on  the  angular 
gyrus,  or  the  occipital  lobe,  or  both  together,  as  the  visual  area. 
Collections  of  accurate  observations  have  demonstrated  the  fact  that 
we  cannot  consider  the  whole  external  face  of  the  occipital  lobe  as 
a cortical  optic  centre,  much  less  the  angular  gyrus,  but  only  the 
internal  face  of  the  occipital  lobe,  and  particularly  of  the  occipital 
pole.  These  observations  have  given  rise  to  strong  suspicion  that 
all  the  experimental  lesions  (besides  those  wrought  by  disease  in 
man)  producing  hemianopsia  and,  on  which  had  been  reared  the 
occipito-external  doctrine  of  the  visual  area,  had  caused  hemian- 
opsia only  to  a degree  corresponding  to  the  extent  of  the  injury  to 
the  external  and  internal  sensory  bundles.  In  this  inquiry  there 
figure  conspicuously  the  observations  and  researches  of  Henschen, 
Vialet,  Dejerine,  Brissaud,  Wilbrand,  etc.,  but  they  do  not  agree 
with  one  another. 

Henschen  holds  that  the  optic  centre  is  limited  to  the  cortex  of 
the  calcarine  fissure,  on  which  would  occur  the  cortical  projection  of 
the  fibres  of  the  retina,  with  this  specialization : that  the  central 
part  of  the  optic  centres,  corresponding  to  the  macula  lutea,  is  found 
in  the  anterior  part  of  the  calcarine  fissure  ; the  inferior  lip  of  the 
calcarine  fissure  would  correspond  to  the  upper,  the  superior  lip 
to  the  lower,  visual  field ; each  half  of  the  macula  would  be  repre- 
sented in  a different  hemisphere.  If  these  views  were  really  supple- 
mented by  either  experimental  research  or  clinical  observation,  that 
part  of  the  cortex  of  the  occipital  lobe  defined  by  Henschen  would  be 
a true  projection  of  the  retina  upon  the  cerebral  cortex.  Henschen 
expresses  a strong  doubt  whether  the  occipital  point  participates  in 
the  formation  of  the  optic  centre,  and  denies  that  the  visual  function 
may  be  situated  also  in  the  cuneus. 

This  hypothesis  of  Henschen  revives  the  general  features  of 
Munk’s  doctrine,  except  that  while  the  latter  refers  the  visual  area 
to  the  external  face  of  the  occipital  lobe  of  the  dog,  Henschen  has 
transferred  its  field  to  the  cortex  of  the  calcarine  fissure.  Vialet  is 


44 


PSYCHIATRY 


opposed  to  the  restricted  localization  held  by  Henschen,  and,  on 
the  ground  of  several  clinical  cases,  and  the  study  of  various  ana- 
tomical data,  has  arrived  at  the  conclusion,  certainly  more  worthy 
of  consideration,  that  the  cortical  visual  field  is  much  more  extensive 
than  Henschen  would  lead  us  to  believe  ; that,  although  unable  to 


AqS,  Aqueduct  of  Sylvius  ; BO,  optic  tract  ; C,  cuneus  ; CC,  corpus  callosum  ; 
CO,  occipital  cornu  ; CGe,  external  geniculate  body  ; CGi,  internal  geniculate 
body  ; CH,  chiasma  ; FOF,  occipito-frontal  bundle  ; FOT,  occipi to- temporal 
bundle  ; I,  insula  ; LF,  frontal  lobe  ; LL,  lingual  lobe  ; L,  limbic  lobe  ; LO,  occi- 
pital lobe  ; LT,  temporal  lobe  ; PC,  parietal  convolution  ; NO,  optic  nerve ; NR,  red 
nucleus  ; NC,  caudate  nucleus  ; OD,  right  eye  ; OG,  left  eye  ; Rad.  ^Opt.,  optic 
radiations  ; RN,  nasal  portion  of  the  retina  ; RT,  temporal  portion  of_the_retina  ; 
Pu,  pulvinar  ; P,  peduncle  ; TQa,  anterior  quadrigeminate  tubercle. 


fix  its  limits,  it  lies  on  the  internal  aspect  of  the  occipital  lobe,  repre- 
sented not  only  by  the  calcarine  fissure  with  its  superior  and  inferior 
lips,  but  also  by  the  cuneus  and  the  cortex  of  the  lingual  lobe.  This 
proposition  would  be  strengthened  by  the  existence  of  fibres  of  pro- 
jection, denied  by  Brissaud,  but  admitted  by  Viadet.  I also  am 
inclined  to  hold  that  the  cuneus  forms  part  of  the  visual  area,  and 


ACOUSTIC  PATHS  AND  CENTRES 


45 


that,  moreover,  it  forms  part  of  the  area  of  greater  functional 
intensity,  drawing  this  conclusion  from  the  intense  degree  of  atrophy 
of  the  cuneus  which  I found  in  a case  of  long-standing  blindness 
in  an  old  servant  who  died  in  the  clinique  of  Sales. 

That  the  question,  then,  of  retinal  projection  propounded  by 
^lunk  and  supported  by  Henschen  does  not  solve  the  other  of  the 
visual  centres  considered  as  registers  of  the  concrete  images  is  demon- 
strated by  the  very  nature  of  vision  and  the  various  factors  whence 
it  results.  We  shall  discuss  this  subject  at  some  length  in  the 
chapter  following.  After  the  perusal  thereof  it  will  become  easy 
for  us  to  understand  how,  even  if  we  could  accept  the  hypothesis 
of  a projection  of  the  retina  upon  the  cerebral  cortex,  we  would  not 
on  this  account  be  warranted  in  assigning  to  this  centre  the  signifi- 
cation of  a visual  centre,  but  only  that  of  an  optic  centre,  which  is 
a totally  different  thing. 

The  visual  centre,  considered  as  a register  of  images,  should  be 
looked  upon  as  much  more  extensive — a matter  which,  from  a clinical 
and  psychological  point  of  view,  is  of  great  importance.  The  most 
recent  clinical  observations  of  Mey,  Cacqueur,  and  Barba  (of  the 
clinique  of  Professor  Rummo),  as  well  as  my  own  experiments,  the 
later  ones  of  Gagnani,  and  the  observations  of  Colucci,  lend  them- 
selves to  the  confirmation  of  the  idea  that  the  optic  area  is  not  to  be 
confined  to  the  calcarine  fissure,  but  is  much  more  extensive,  as  I 
have  said  above.  Vialet’s  scheme  (Fig.  i6)  helps  us  to  understand 
all  the  facts  now  elucidated. 

Acoustic  Paths  and  Centres 

In  the  organ  of  Corti  in  the  cochlea,  as  well  as  in  the  epithelium 
of  the  auditory  crest  of  the  semi-circular  canal,  the  nerve  elements 
terminate  with  free  intercellular  ramifications,  like  those  of  the 
olfactory  nerve  (Retzius,  R.  y Cajal).  These  free  arborizations 
belong  to  the  polar  cells,  which  are  situated  at  a distance  from  the 
epithelium,  thus  differing  from  what  we  find  in  the  case  of  the 
olfactory  mucous  membrane  (R.  y Cajal).  The  axis-cylinder  pro- 
cesses of  the  bipolar  cells  go  to  form  the  acoustic  or  cochlear  nerve. 

I shall  now  mention  here  only  a few  points  which  are  of  use  in 
furnishing  a fairly  precise  knowledge  of  the  course  of  the  acoustic 
paths  from  the  nuclei  to  the  cortex  ; these  paths  have  been  defined 
especially  by  the  researches  of  Flechsig,  Onufrowicz,  Bechterew, 
Baginsky,  and  Spitzka.  Of  the  nuclei  of  the  eighth  nerve,  the 
anterior  should  be  regarded  as  the  true  nucleus  of  the  acoustic  nerve, 
being  related  with  the  trapezoid  body  on  the  one  hand  and  the 
cochlear  nerve  on  the  other  ; the  latter  should  be  considered  as  the 
true  acoustic  nerve,  while  the  vestibular  nerve — which,  by  the  way, 
gets  a medullary  sheath  before  the  cochlear  nerve — should  be 
regarded  as  designed  for  some  other  function. 


46 


PSYCHIATRY 


Beginning,  then,  at  the  cochlear  nerve  which  goes  to  the  anterior 
nucleus  of  the  acoustic  nerve,  the  acoustic  paths  are  formed  in  great 
measure  by  the  trapezoid  body  (Fig.  17),  whence  a portion  of  the 
fibres  passes,  according  to  Flechsig,  to  the  lateral  lemniscus,  which 
also  receives  many  fibres  from  the  superior  olive,  and  enters  the 
posterior  quadrigeminate  body. 

According  to  Onufrowicz,  the  true  auditory  nerve  would  be 


VIII,  Acoustic  nerve  ; rap,  raa,  posterior  and  anterior  roots  of  the  acoustic 
nerve  ; na,  anterior  nucleus  of  the  acoustic  nerve  ; ta,  acoustic  tubercle  ; stra, 
medullary  or  acoustic  striae  ; strs,  medullary  striae  of  Monakow  : cr.  restiform 
body  ; nv,  vestibular  nucleus  ni,  so-called  middle  acoustic  nucleus  ; nD,  Deiter’s 
nucleus  ; Vila,  ascending  root  (?)  of  the  facial  ; VIIc,  descending  root  of  the  facial  ; 
nVII,  nucleus  of  the  facial  ; Oi,  superior  extremity  of  the  large  ohve  ; fc,  central 
path  to  the  calotte  ; Os,  superior  olive  ; tr,  trapezoid  body  ; Py,  pyramid  ; nci,  in- 
ferior central  nucleus  ; fna,  bundles  from  the  superior  olive  to  the  nucleus  of  the 
abducens  ; fnt,  bundle  of  the  lateral  fillet  of  Red  ; V,  ascending  root  of  the  trige- 
minus ; sn,  substantia  gelatinosa  ; Inij,  Imii,  portions  of  the  fillet  of  Red. 


formed  by  the  posterior  root  (acoustic),  and  would  take  origin  from 
the  auditory  tubercle — a gray  mass  described  by  some  authorities 
as  a part  of  the  flocculus.  This  same  posterior  root,  according  to  the 
last-mentioned  author,  would  pass  through  the  anterior  acoustic 
nucleus  without  stopping,  finally  terminating  in  the  acoustic 
tubercle. 

In  our  opinion,  the  researches  of  Bechterew  and  Flechsig  should 
be  considered  of  greater  value  from  the  fact  that  the  acoustic 


ACOUSTIC  PATHS  AND  CENTRES 


47 


tubercle  in  man  is  little  developed,  while  the  anterior  acoustic 
nucleus  is  rather  well  developed  ; and,  on  the  other  hand,  if,  as 
Onufrowicz  holds,  the  trapezoid  body  is  not  found  wholly  degene- 
rated after  destruction  of  the  internal  ear  in  animals,  it  is  because,  in 
his  opinion,  the  trapezoid  body  is  not  composed  of  acoustic  fibres 
alone,  but,  as  Flechsig  demonstrated,  contains  fibres  of  various 
natures,  among  which  are  commissural  fibres  passing  between  the 


Fig.  1 8. — System  of  the  Central  Course  of  the  Auditory  Fibres  (System 
OF  THE  Second  Order). 

Nc,  Cochlear  nerve  ; vk,  anterior  nucleus  ; ct,  trapezoid  body ; Tk,  nucleus  of 
the  trapezoid  body  ; oO,  superior  olive  ; Ta,  acoustic  tubercle  ; Sta,  striae  acousticae; 
IS,  lateral  lemniscus  ; ISk,  nucleus  of  the  lateral  lemniscus  ; Ba,  brachia,  and  Bak, 
decussation  of  the  brachia  of  the  corpora  quadrigemina  ; oV,  anterior  corpus 
quadrigeminus  ; uV,  posterior  corpus  quadrigeminus ; Ri,  cerebral  cortex  ; Rb, 
cortical  paths;  R,  raphe.  (From  Bechterew.) 


two  anterior  acoustic  nuclei,  like  the  fibres  of  the  posterior  commissure 
of  Gudden  between  the  primary  optic  centres. 

This  same  fact  is  proved  in  the  research  work  of  Baginsky,  who 
has  shown  by  the  method  of  absconding  degeneration  that  the 
acoustic  apparatus  would  in  reality  be  constituted  by  the  anterior 
nuclei  of  the  acoustic  nerve.  He  seems  likewise  to  have  discovered 
definite  relations  between  it,  the  trapezoid  body,  and  the  superior 
olives.  Besides  this,  he  apparently  confirms  the  relations  estab- 
lished by  Monakow,  by  the  method  of  descending  degeneration. 
Monakow,  in  fact,  has  found  atrophy  in  the  internal  geniculate  body 


48 


PSYCHIATRY 


and  posterior  quadrigeminate  body  as  the  result  of  destruction  of 
the  cortical  auditory  centre.  If  proof  is  still  wanting  that  the 
acoustic  paths  are  represented  by  the  trapezoid  body,  the  posterior 
quadrigeminate  body,  and  the  internal  geniculate  body,  we  might 
call  into  requisition  the  result  of  the  interesting  research  of  Spitzka, 
who  has  found  in  the  crustaceans,  which  have  a highly  developed 
auditory  organ,  a correspondingly  great  development  of  the  trapezoid 
body,  besides  the  posterior  quadrigeminate  and  internal  geniculate 
bodies.  According  to  him,  the  fibres  of  the  acoustic  nerve  would 
pass  into  the  trapezoid  body  of  the  same  side,  whence,  after  decus- 
sating, they  would  proceed  through  the  lateral  lemniscus  to  the 
posterior  quadrigeminate  and  internal  geniculate  bodies  of  the  oppo- 
site side.  The  lateial  lemniscus,  then,  contains  auditory  fibres 
establishing  relations  between  the  superior  olive — which  may  be 
considered  as  an  acoustic  station — and  the  posterior  quadrigeminate 
body  by  means  of  fibres  from  the  trapezoid  body  and  the  acoustic 
striae  of  the  opposite  side.  The  acoustic  fibres  coming  from  the 
internal  geniculate  body  and  the  optic  thalamus  would  pass  through 
the  sublenticular  part  of  the  internal  capsule,  and,  according  to 
Brissaud,  Flechsig,  Vialet,  and  others,  would  pass  through  the 
external  sensory  bundle  into  the  corona  radiata  in  the  temporo- 
sphenoidal  lobe,  and  thence  to  the  cortex  of  the  first  and  second 
temporo-sphenoidal  convolutions  {vide  Scheme,  Fig.  i8).  The 
cortical  auditory  centre  would  be  constituted,  then,  by  these  two 
convolutions,  more  especially  by  the  middle  and  posterior  parts  of 
them. 


The  Paths  and  Centres  of  Common  Sensibility 

The  tactile,  thermic,  painful,  etc.,  waves  are  received  by  special 
nerve  organs  placed  in  the  skin,  and  are  transmitted  through  centri- 
petal fibres  to  the  unipolar  cells  of  the  intervertebral  ganglia,  whose 
processes  emerge  to  form  the  fibres  of  the  posterior  roots  (His, 
Kolliker,  Cajal).  These,  after  reaching  the  spinal  cord,  divide  into 
two  branches — an  ascending  and  a descending — terminating  in  the 
posterior  columns  and  in  the  substance  of  Rolando. 

The  outermost  fibres  of  the  posterior  root  penetrate  the  cord,  run 
vertically  upwards  for  a distance,  and  are  then  deflected  into  the 
gelatinous  substance  of  Rolando.  The  middle  fibres  penetrate 
directly  the  gray  substance  of  the  posterior  cornu,  where  they  come 
into  relations,  by  means  of  their  arborizations,  with  the  cells  of  the 
said  cornu.'  The  innermost  run  obliquely  upwards  in  the  cuneiform 
column,  describing  a curve  with  its  convexity  inwards,  and  have 
various  destinations  ; some,  the  most  internal,  constitute  the  zone 
of  entrance  of  the  posterior  roots  (Westphal),  and  form  by  preference 
the  centripetal  path  of  deep  sensibility  and  of  the  tendon  reflexes  ; 
■others  are  directed  towards  the  column  of  Clarke,  where  they  come 


SENSORY  PATHS  AND  CENTRES  49 

in  contact  with  the  arborizations  of  the  cells  of  that  column,  from 
which  there  issue  processes  going  to  the  direct  cerebellar  tract  ; 
others,  finally,  run  for  a certain  distance  upwards  and  inwards,  and 
pass  into  the  column  of  Goll  (gracilis),  being  continually  pushed 
further  inwards  by  the  analogous  fibres  of  the  other  roots,  which 
successi\'ely  enter  the  spinal  cord  from  below  upwards.  In  this 
manner  the  long  fibres  of  the  sacral,  lumbar,  and  dorsal  roots  pass 
in  the  cervical  region  through  the  column  of  Goll,  which  at  that  level, 
according  to  Dejerine  and  Sottas,  does  not  contain  either  endogenous 


Fig.  19. 

laterals  i°^  the  posterior  commissure  ; b,  col- 

thl  nict  ^ column  of  Goll  going  direct  to  the  posterior  cornu  ; c,  collaterals  of 
posterior  direct  to  the  central  gray  substance  and  also  to  the 

column  f coUatf;  r V collaterals  ; e,  collateral  fibres  of  the  anterior 

the  commikure  commissure;  g,  their  tract  in 

Jo  tS  anterior  ’ri5'  ° f commissural  cell,  k.  passing  through  the  commissure 

j-  1 r umn  , 1,  tract  of  this  fibre  in  the  commissure  • j axis  cvlinder 

«fiJh\ffurcrted  a^^^  interior  root  ; 1,  cell  of  the  anterior  cornu 

cell  o ax^s  ctlt^de?^  f"  “™n'i=*sural  axis  cylinder  ; n,  associative 

marginal  cdl  nVth^  ‘ column  of  Clarke  ; p,  fibre  coming  from  s,  a 

r biSrcation  of  the  ‘fttitsverse  section  of  an  axis  cylinder  ; 


fibres  or  descending  root  fibres.  Many  of  the  fibres  forming  the 
columna  gracilis,  however,  are  only  collaterals  idiscovered  by  Golgi 
and  confirmed  by  Kolliker,  Van  Gehuchten.'  Retzius,  Ramon  y 
ajal,  etc.)  of  the  medullated  fibres  of  the  posterior  root.  They  arise 
at  right  angles  from  the  nerve  processes,  and  end  in  free  terminal 
arbonzatmns.  Some  are  root  fibres  coming  directly  from  the  other 
=ide  as  affirmed  by  Lowenthal,  but  denied  by  others  who  have  con- 
ned their  e.xperimental  lesions  to  the  posterior  roots  (Mott,  Dejerine, 

4 


50 


PSYCHIATRY 


Spiller,  and  Russell).  I mention  here  the  most  important  of  these 
collaterals,  according  to  Cajal,  and  they  are  represented  along  with 
the  others  in  Fig.  19. 

Collaterals  of  the  Lateral  Column. — These  ramify  within 
the  central  region  of  the  gray  substance.  One  part  of  them  reaches 
the  posterior  commissure,  and  terminates  in  the  posterior  cornu  and 
the  central  gray  substance  of  the  opposite  side. 

Collaterals  of  the  Posterior  Column. — Some  of  these  become 
detached  either  from  the  fibres  of  the  posterior  root  before  its 
division  into  ascending  and  descending  branches,  or  from  the  ascend- 
ing branch  of  it,  and  terminate  in  the  anterior  cornu  ; they  are  the 
reflexo-motor  fibres  of  Kolliker.  Some,  again,  go  to  form  branches 
of  an  arborization  shut  up  in  the  head  of  the  posterior  cornu, 
whilst  others,  detached  from  the  fibres  of  the  columns  of  Goll, 
terminate  with  arborizations  in  the  column  of  Clarke.  Finally, 
others  from  the  column  of  Goll  cross  the  posterior  part  of  the  pos- 
terior commissure,  and  terminate  in  the  head  of  the  posterior  cornu 
(Fig.  20). 

Ludwig  had  attempted  experiments  to  demonstrate  that  a con- 
siderable number  of  the  sensory  fibres  pass  in  the  lateral  columns  ; 
not  only  is  this  hypothesis  supported  by  Schiff  and  Landois,  but  two 
eminent  English  physicians  would  appear  to  have  brought  forward 
clinical  proof  of  this  doctrine.  Gowers  observed  in  an  individual  . 
who  had  sustained  crushing  of  the  spinal  cord,  not  only  degeneration  , 
of  the  columns  of  Goll  above  the  lesion,  but  also  tracts  of  ascending 
degeneration  in  a zone  situated  in  front  of  the  pyramidal  bundle,  1 
and  behind  the  lateral  process  of  the  anterior  cornu.  Byrom  Bram- 
well,  in  a case  of  severe  transverse  myelitis,  found,  besides  degenera-  ? 
tion  of  the  ascending  fibres  in  the  columns  of  Goll,  a degenerate' 
bundle  in  front  of  the  pyramidal  bundle  and  behind  the  anterior 
cornu.  Hadden  and  Sherrington  have  published  an  accurate 
study  of  these  fibres,  and  from  the  entire  collection  of  researches?: 
published  up  till  now  it  is  quite  certain  that  in  front  of,  and  partlyjj 
within,  the  direct  cerebellar  tract  and  the  pyramidal  tract  there:; 
exists  another  with  its  base  from  without  inwards,  going  deeply  intcj 
the  mixed  fundamental  zone  of  the  antero-lateral  column,  and^; 
extending  in  front  as  a marginal  zone  of  the  said  column  as  far  as  the 
zone  of  entrance  of  the  anterior  roots.  It  has  recently  been  demon- 
strated that  the  fibres  of  this  tract  do  not  directly  belong  to  the 
posterior  root,  because  they  do  not  degenerate  as  the  result  of  section 
of  the  posterior  roots.  In  consequence  of  a profound  lesion  and 
crushing  of  the  spinal  medulla,  however,  the  given  tract  is  found 
more  degenerate  on  the  side  opposite  to  that  in  which  the  degenera- 
tion of  the  columns  of  Goll  is  more  markea — that  is  to  say,  the  fibres 
composing  it  are  indirectly  derived  from  the  posterior  roots,  but 
directly  from  the  spongy  substance  of  the  posterior  cornu  of  the 
opposite  side.  It  is  therefore  an  endogenous  tract,  as  is  also  the 


SENSORY  PATHS  AND  CENTRES 


51 


small  tract  which,  according  to  Schultze,  forms  a kind  of  comma 
in  the  upper  and  inner  part  of  the  centrum  ovale  of  Flechsig,  ob- 
served also  by  Hoche,  Achalme,  and  Theohari,  and  which  possibly 
coincides  with  the  triangle  of  Ganbault  and  Philippe.  The  fibres 
comprising  it  would  appear  to  be  designed  to  unite  the  upper  regions 
of  the  medulla  with  the  terminal  cone  ; some,  however,  consider 


BUTION  OF  THE  NeRVE  CeLLS  IN  THE  LaTTER. 

rpe,  Postero-lateral  root  ; rpi,  postero-median  root  ; p (in  the  middle  of  the 
figure),  collateral  of  a posterior  root  fibre  which  reaches  the  opposite  side  through 
the  dorsal  commissure  ; t,  collateral  of  a posterior  root  fibre  in  the  column  of  Clarke  • 
r,  collateral  of  a posterior  root  fibre  to  the  anterior  cornu  ; u,  collateral  to  the  central 
gray  substance  ; s,  collateral  to  the  posterior  cornu  ; n,  fibre  of  the  limiting  zone 
terminating  in  the  gray  substance  ; fp,  fp',  direct  fibres  from  the  lateral  and  central 
pyramidal  columns  to  the  cells  of  the  anterior  cornu  ; 1,  fibre  from  the  fundamental 
bandelet  of  the  lateral  column,  and  m,  analogue  from  the  fundamental  bandelet  of 
the  anterior  column  penetrating  the  gray  substance  ; e-c,  commissural  cells  ; rr,  root 
cells  ; aa,  cells  of  the  lateral  columns  ; bb,  cells  of  the  posterior  colmuns  • d ’ cells 
of  Golgi  with  short  axis  cylinders  ; fg,  columns  of  Goll  ; gi,  part  of  the  column  of 
Goll  limiting  the  dorsal  section  ; gl,  intermediary  zone  (Zwischenschicht)  ; brs,  bpa, 
bpm,  posterior  middle  and  anterior  parts  of  the  column  of  Burdach  • z externai 
root  region  (Randzone)  ; p,  crossed  pyramidal  bundle  ; pi,  anterior  pyramidal 
bundle  ; cl,  direct  cerebellar  bundle  ; al,  tract  of  Gowers  ; i,  middle  bandelet  of  the 
lateral  column  ; fbl,  fundamental  bundle  of  the  lateral  column  ; fba,  fundamental 
bundle  of  the  anterior  column  ; ra,  ventral  or  anterior  root. 

these  fibres  to  be  exogenous,  and  would  regard  them  as  the  de- 
scending branches  of  the  fibres  of  the  posterior  root.  According  to 
Tiis  view,  the  two  posterior  columns  would  be  formed  of  exogenous 
ibres  in  great  preponderance  ; the  direct  cerebellar  column  and  the 
-ract  of  Gowers,  on  the  other  hand,  are  formed  of  endogenous  fibres. 

Each  of  these  great  sensory  paths  of  the  spinal  medulla— the 
posterior  median  column  of  Burdach  and  the  ascending  lateral 

4—2 


52 


PSYCHIATRY 


column  of  Gowers  (not  to  speak  at  present  of  the  direct  cerebellar 
column  which  goes  directly  through  the  restiform  body  to  the  cere- 
bellum) becomes  interrupted  in  an  important  station,  whence  issue 
new  paths,  which  we  may  consider  for  the  most  part  as  the  con- 
tinuation of  the  spinal  paths  to  the  basal  ganglia  and  the  cerebral 
mantle.  These  bulbar  stations  are  the  so-called  nuclei  or  cell 
masses  of  the  column  of  Goll — the  cuneiform  column  and  the  lateral 
column.  In  Fig.  21  the  position  and  relations  of  these  nuclei  are 
clearly  shown.  All  the  fibres  of  the  said  tracts,  however,  do  not 
become  interrupted  in  the  nuclei  in  question.  More  recent  researches 
would  seem  to  demonstrate  the  existence  of  fibres  passing  directly 
from  the  lateral  columns  to  the  corpora  quadrigemina  (Schafer), 
and  of  others  proceeding  through  the  lateral  fillet  of  Reil  to  the 
anterior  corpora  quadrigemina,  and  to  the  optic  thalamus  (spino- 
quadrigeminal  and  spino-thalamic  fibres  — Mott),  whilst  others 
detach  themselves  from  the  tract  of  Gowers  to  pass  to  the  lateral 
fillet  of  Reil,  and  thence  to  the  internal  geniculate  body  and  the 
posterior  commissure,  or  to  the  external  nucleus  of  the  thalamus 
(Quensel,  Solder). 

Four  large  paths  exist,  then,  between  the  spinal  medulla  and  the 
higher  centres — two  posterior  tracts,  the  cuneiform  and  the  gracile, 
which  are  for  the  most  part  exogenous  ii.e.,  formed  of  fibres  coming 
from  the  posterior  roots),  and  two  lateral  tracts,  the  direct  cere- 
bellar of  Flechsig  and  the  tract  of  Gowers,  formed  of  endogenous 
fibres  (of  spinal  origin).  Besides  these  tracts,  there  exist  the  above- 
mentioned  direct  paths,  which  are  not  interrupted  in  the  nuclei  of 
the  medulla  oblongata,  and  also  other  endogenous  fibres  found  especi- 
ally in  the  rest  of  the  lateral  columns. 

Some  of  the  conducting  paths  of  common  sensibility  and  their 
collaterals  decussate  in  the  spinal  medulla,  others  are  direct.  The 
question  of  decussation  has  in  recent  times  given  rise  to  more  dis- 
cussion than  ever.  While  Brissaud,  Lloyd,  and  Ra}^mond  still 
adhere  to  the  doctrine  of  spinal  decussation  of  the  sensory  fibres, 
others,  such  as  Mott,  Gutch,  and  Horsley,  Dejerine  and  Thomas, 
deny  it  on  grounds  of  clinical  and  anatomical  facts  of  great  im- 
portance. As  an  instance  of  the  great  increase  in  the  doubts  and 
difficulties  which  the  original  scheme  of  Brown-Sequard  presented 
with  an  intelligible  simplicity,  it  is  worth  while  mentioning  the 
crossed  tract  of  Edinger,  who,  in  two  works,  has  insisted  on  the 
presence  of  secondary  sensory  fibres,  which  take  origin  from  the 
cells  of  the  anterior  and  posterior  cornua,  decussate  in  the 
anterior  commissure,  pass  into  the  antero-lateral  column  of  the 
opposite  side,  and  proceed  as  an  anterior  fundamental  sensory 
bundle  to  the  fillet  of  Reil  in  the  interolivary  layer.  With  such  an 
undecipherable  distribution  and  complication  of  sensory  paths  in 
the  spinal  medulla,  it  is  rather  difficult  nowadays  to  assign  to  each 
individual  tract  and  to  the  gray  substance  of  the  posterior  cornua 


SENSORY  PATHS  AND  CENTRES 


53 


the  functions  of  transmitting  specific  forms  of  sensibility  ; and 
rather  than  discuss  past  and  recent  hypotheses,  I deem  it  more 
advantageous,  after  the  mere  mention  of  this  question,  to  turn  our 
attention  again  to  the  course  of  the  sensory  fibres  from  the  bulb 
upwards. 

From  the  nucleus  gracilis  and  nucleus  cuneiformis  originate 
fibres  which,  advancing  forwards  and  upwards  in  a curve  with  its 


Fig.  21. — Section  of  the  Medulla  Oblongata  at  the  Level  of  the  Decussa- 
tion OF  THE  Lemniscus. 

p,  Pyramid  ; oi,  inferior  olive  ; oi',  superior  olive  (Nebenolive)  ; nla,  nucleus 
of  the  antero-lateral  column  ; nip,  nucleus  of  the  postero-lateral  column  ; fc,  path 
of  the  lateral  cerebellar  column  ; V,  trigeminus  ; sn,  substantia  gelatinosa  ; nfce,  a 
part  of  the  lateral  nucleus  of  the  cuneiform  column  ; nfg,  nucleus  of  the  columnus 
gracilis  ; nfc,  nucleus  of  the  cuneiform  column  ; crs,  posterior  or  superior  decussa- 
tion ; fi,  interolivary  layer  ; external  to  crs  and  fi  is  the  reticulated  gray  substance 
(Bechterew). 

convexity  outwards,  so  as  to  surround  the  central  carnal  with  con- 
centric curves  (Fig.  21),  decussate  at  an  acute  angle  behind  the  pyra- 
mids (posterior  decussation),  to  form  the  interolivary  layer  or  that 
of  the  lemniscus.  The  lemniscus,  according  to  Edinger,  would  be 
joined  by  fibres  coming  apparently  from  the  anterior  column,  but 
having  their  origin  in  the  posterior  and  anterior  cornua,  and  arriving 
at  the  anterior  column  by  means  of  the  anterior  commissure. 

It  is  evident,  judging  from  the  constitution,  still  not  quite  clear, 
of  the  median  lemniscus,  that,  as  the  result  of  its  crossed  relations 


54 


PSYCHIATRY 


with  the  sensory  nuclei  of  the  medulla  oblongata,  it  ought  to  be 
considered  as  the  most  important  sensory  path.  It  is  reinforced 
by  fibres  coming  from  cell  groups — the  so-called  nuclei  of  the 
lemniscus — interposed  along  the  course  of  its  fibres,  and  also  by  the 
fibres  of  the  nucleus  reticularis  tegmenti  fontis,  which  can,  at  least 
in  part,  be  considered  as  a continuation  of  the  paths  of  the  lateral 
column  of  Gowers,  while  those  coming  from  the  trapezoid  body,  the 
medullary  striae  of  the  acoustic  nerve  (Monakow)  and  the  superior 
olive,  pass  through  the  lateral  lemniscus. 

The  lemniscus,  then,  is  distinguished  into  two  bundles  (leaving 
out  of  account  the  lemniscus  of  the  pes,  which  is  not  a sensory  path) : 


Fig.  22. — ^Section  of  the  Medulla  Oblongata  in  Front  of  that  shown  in 

Fig.  21. 

Nar,  Arcuate  nucleus;  fae,  external  arciform  fibres;  Py,  pyramid;  Lm,  lem- 
niscus ; fsla,  anterior  longitudinal  sulcus  ; Oaa,  anterior  accessory  olivary  nucleus  ; \ 

No,  olivary  nucleus  ; Ra,  raphe  ; Oae,  external  accessory  olive  ; Nit,  nucleus  of  the 
lateral  column  ; Na,  nucleus  ambiguus  ; Sgl,  substantia  gelatinosa  ; Va,  ascending 
root  of  the  fifth  nerve  : the  zones  numbered  are  the  nuclei  of  the  corresponding 
cranial  nerves. 

the  lateral  bundle,  which  can  be  considered  in  preference  an  acoustic 
path,  as  above  mentioned,  and  the  mediam  bundle,  which,  on  the  con-  ^ 
trary,  should  be  regarded  preferably  as  a path  of  common  sensi-  .-i 
bility.  The  median  lemniscus  gives  off  fibres  to  the  anterior  J 
quadrigeminate  body,  while  the  greater  part  of  it  passes  to  the  sub-  I 
thalamic  substance  (according  to  some,  forming  connections  with  i| 
the  internal  segment  of  the  lenticular  nucleus),  to  the  optic  thalamus,  f 
and,  just  in  front  of  the  pulvinar,  to  the  postero-external  part  of  the 
external  nucleus  of  the  thalamus,  which  is  considered  as  a second  ? 
important  station  for  the  sensory  fibres.  1 

It  is,  perhaps,  not  a sensory  path  only,  for  it  also  exhibits  i 
degeneration  in  a descending  direction  (Flechsig,  Hdsel,  Bruce,  and 
others).  ■ • ' |7 


SENSORY  PATHS  AND  CENTRES 


55 


Other  fibres  of  the  posterior  nuclei,  especially  those  coming  from 
the  nucleus  of  the  column  of  Goll  (Edinger),  pass  to  the  reticulate 
substance,  which,  as  already  noted,  contains  fibres  of  the  lateral 
nucleus.  If  the  fibres  of  the  antero-lateral  column  become  inter- 
rupted in  the  latter,  one  can  understand  how,  besides  the  lemniscus, 
the  reticulate  substance  also  should  be  regarded  as  an  important 
sensory  path. 

It  is  evident  from  what  has  been  said  that  the  majority  of  the 


Fig.  23. — Course  of  the  Sensory  Fibres  to  the  Level  of  the  Anterior  Corpus 

Quadrigeminum. 

no,  Optic  tract  ; ogs,  anterior  quadrigeminate  body  ; fep,  bundles  of  the  posterior 
commissure  ; Is,  bundle  of  the  anterior  quadrigeminate  body  to  the  optic  thalamus  ; 
cp,  corpus  parabigeminus  ; ni,  innominate  nucleus  ; 1,  fillet  of  Reil  (lemniscus)  ; 
sn,  substantia  nigra  ; fe,  external  bundle  of  the  pes  of  the  cerebral  peduncle ; p,  pyra- 
midal bundle  ; Ip,  accessory  lemniscus  (Bechterew)  ; Isp,  bundle  given  off  from  the 
lemniscus,  penetrating  the  cerebral  peduncle  ; fi,  internal  bundle  of  the  cerebral 
peduncle  ; III,  oculo-motor  nerve  ; pcc,  peduncle  of  the  mammillary  body  ; crv, 
ventral  decussation  of  the  tegmentum  ; fr,  fasciculus  retroflexus  ; nr,  red  nucleus  ; 
fc,  central  path  of  the  tegmentum ; fp,  posterior  longitudinal  bundle  ; ndlll,  posterior 
nucleus  of  the  oculo-motor  nerve  ; nm,  median  nucleus  of  the  oculo-motor  nerve  ; 
erf,  decussation  of  fegs,  bundles  of  the  deep  medullary  substance  of  the  anterior 
quadrigeminate  body  ; aS,  aqueduct  of  Sylvius  (Bechterew). 


sensory  fibres  of  the  lemniscus  do  not  pass  through  the  capsule,  but 
are  interrupted  once  in  the  optic  thalamus.  Opinions  differ  con- 
cerning this  interruption  of  the  sensory  fibres  in  the  thalamus,  but 
the  experimental  data  furnished  by  the  researches  of  Monakow, 
Singer  and  Mfinger,  and  Mott,  enable  us  to  decide  in  favour  of  an 
interruption  (free  terminations  of  the  respective  neurones)  in  the 
optic  thalamus.  Vice  versa,  the  experiments  of  Ferrier,  Turner, 
and  Tschermak  would  lead  us  to  believe  that  the  fibres  of  the  lem- 


56 


PSYCHIATRY 


niscus  pass  by  the  optic  thalamus,  the  internal  capsule,  the  lenticular 
nucleus,  and,  lastly,  by  the  external  capsule,  so  as  to  reach  the  cortex 
of  the  parietal  lobe.  The  results  of  clinical  observation  do  not  all 
agree.  Those  of  Hosel  and  Flechsig  are  antagonistic  to  those  of 
Mahaim.  Hosel  supports  Flechsig’s  conclusion  that  the  fillet  of 
Reil  (lemniscus)  sends  fibres  directly  to  the  cortex,  while  Mahaim 
confirms  the  results  of  Monakow’s  researches.  Mahaim  has  observed 
that  the  fibres  of  the  fillet  in  the  calotte  are  closely  mingled  with 
some  of  the  fibres  of  the  subthalamic  region,  while,  on  the  other  hand, 
the  cortical  fibres  of  the  fillet,  along  with  other  fibres  of  different 
origin,  penetrate  the  fenestrated  layer  of  the  thalamus  and  the 
internal  and  external  medullary  laminae,  and  ramify  in  the  internal 
a.nd  external  nuclei  of  the  optic  thalamus.  The  views  of  Monakow 
and  Mahaim  are  further  supported  by  the  researches  of  Biels- 
chowsky,  Dejerine,  Greiwe,  Schlesinger,  and  Mayer.  At  this  point  a 
very  important  question  forces  itself  upon  us  for  consideration. 

We  have  already  said  that  the  lemniscus  forms  three  tracts — 
the  lateral,  regarded  chiefly  as  an  acoustic  sensory  path  ; the 
median,  which  is  a path  of  common  sensibility  ; and  the  third 
bundle,  which  might  be  called  the  lemniscus  of  the  pes  (pes  lem- 
niscus profondo),  and  which,  according  to  Dejerine  and  Long,  is 
annexed  or  conjoined  to  the  median  fillet  of  Reil,  but  is  composed 
of  a system  of  fibres  which  are  offshoots  from  the  pes  of  the  cerebral 
peduncle,  and  therefore  very  probably  motor.  We  ought  not, 
however,  to  regard  the  lemniscus  as  a solitary  sensory  path,  because, 
besides  the  reticulated  substance,  other  sensory  paths  exist.  On 
the  contrary,  according  to  the  most  recent  researches  of  Schlesinger, 
Gee,  and  Tooth,  the  fillet  of  Reil  would  be  placed  in  the  second  rank 
as  a sensory  path. 

Having  made  it  clear  that  the  sensory  paths  of  the  median  fillet 
of  Reil  and  the  reticulated  substance  of  the  pons  and  tegmentum  are 
interrupted  in  the  optic  thalamus,  it  is  easy  to  understand  how 
there  should  emerge  from  it  another  system  of  fibres  which  pass 
through  the  internal  capsule  to  reach  the  cortex.  It  is  through 
the  posterior  segment  of  the  internal  capsule  that  the  thalmo- 
cortical  fibres  pass,  and  at  this  point  some  of  them  are  intermingled 
with  the  pyramidal  fibres  of  the  limbs  (Dejerine).  Those,  however, 
which  penetrate  the  thalamus  and  lenticular  nucleus  cross  the  sub- 
optic and  retrolenticular  tracts.  This  tract,  meanwhile,  must  not 
be  considered  as  exclusively  a bundle  of  common  sensibility,  be- 
cause it  contains  thalmic  radiations,  fibres  of  projection  proceeding 
fiom  the  occipital  and  parietal  lobes  to  the  central  nuclei  of  the 
thalamus  and  the  centrifugal  bundle  of  the  temporal  lobe  or  bundle 
of  Tiirk-Meynert. 

Still  more  difficult  is  the  delimita,tion  of  a cortical  sensory  area 
for  common  sensibility.  For  example,  Ferrier  considers  the  hippo- 
campus as  the  cortical  area  of  common  sensibility,  and  Munk  holds 


SENSORY  PATHS  AND  CENTRES 


57 


tli6  motor  zone  to  be  nothing  else  than  a sensory  zone  for  common 
sensibility.  On  the  other  hand,  Luciani  regards  the  motor  zone  as 
senso-motor,  while  Monakow  and  Bechterew  locate  common  sen- 
sibility in  the  parietal  lobe.  .Schafer,  again,  assigns  to  common 
sensibility  a part  of  the  convolution  of  the  corpus  callosum,  and 
Hosel  considers  the  Rolan  die  zone  as  an  ultimate  station  of  the  fillet 
of  Reil ; further,  there  is  the  very  conflicting  evidence  of  not  a few 
clinical  observations,  including  that  of  Hosel  himself,  certainly 
incomplete  from  the  clinical  side.  Hence,  though  opinion  is  far  from 
unanimous,  still  we  are  enabled  to  form  some  idea  of  the  diverse 
mechanism,  in  different  cases,  of  disturbances  of  sensibility  resulting 
from  an  apparently  identical  lesion. 

Indeed,  while  many  destructive  foci  in  the  Rolandic  zone  give 
rise  to  disturbances  of  sensibility,  insignificant  as  compared  with 
motor  disturbances,  other  foci  produce  both  paralysis  and  loss  of 
sensibility  for  a time.  AgaJn,  some  lesions  of  the  parietal  lobe  have 
run  their  course  without  important  disturbance  of  sensibility,  while 
in  others,  on  the  contrary,  such  disturbance  has  been  most  marked. 

Amongst  many  other  cases  I recall  that  of  a man,  aged  fifty-seven, 
who,  after  a cerebral  attack,  with  loss  of  consciousness  for  a short 
time,  remained  hemiparetic  on  the  left  side  and  subject  to  attacks 
of  vertigo.  On  examination,  I found  marked  paresis  of  the  left 
inferior  limb,  the  paresis  of  the  upper  limb  having  almost  disappeared ; 
no  paralysis  of  the  face  or  tongue  ; anaesthesia  and  analgesia  of 
the  left  upper  limb,  and  also  of  the  lower,  as  far  as  the  knee  ; hypo- 
aesthesia  from  the  knee  downwards  ; bilateral  homonymous  hemian- 
opsia of  the  left  ocular  field  ; some  psychic,  disturbances,  disorien- 
tation and  confusion.  In  two  cases  of  a destructive  focus  in  the 
occipital  lobe,  somewhat  extensive  in  both,  I have  likewise  found 
marked  hypoaesthesia  on  the  opposite  side.  It  is  very  probable  that 
in  the  first  case  there  may  have  been  a destructive  focus  of  the 
parietal  lobe  on  the  right  side,  deep  enough  to  injure  the  optic  radia- 
tions, together  with  a.  lesion  of  some  of  the  fibres  of  projection  of 
the  cortical  zone  for  the  inferior  limb  (more  above  and  behind). 
The  profound  anaesthesia,  with  very  slight  paresis  of  the  upper 
limb,  not  being  capable  of  explanation  by  a lesion  of  the  Rolandic 
zone  or  its  fibres  of  projection,  nor  being  probably  due  to  a small 
lesion  of  the  internal  capsule  (as  in  the  case  of  a crural  monoplegia 
with  hemianopsia),  must  be  attributed  to  the  parietal  lesion. 

As  the  literature  of  analogous  cases  is  not  at  all  scarce,  and  as, 
on  the  other  hand,  it  is  well  known  that  lesions  of  the  Rolandic 
zone  often  produce  only  motor  paralysis,  leaving  cutaneous  sen- 
sibility unaltered,  it  should  be  agreed  (unless  contradicted  by  more 
rigorous  examination  in  future  observations  directed  towards  the 
determination  of  not  only  the  extent  of  the  lesion,  but  also  of  its 
exact  whereabouts  and  depth)  that,  in  all  probability  there  exists 
on  the  cerebral  cortex  a very  extensive  area  for  common  sensibility, 


58 


PSYCHIATRY 


with  centres  of  greater  functional  intensity,  and  that  the  exact 
situation  of  these  is  not  fixed  and,  unvarying  in  the  same  way  as 
those  of  sight  and  hearing,  nor  do  they  attain  an  equal  development 
in  all  men. 

It  is  evident  that  one  part  of  the  cortical  tactile  sphere  is  closely 
connected  with  the  olfactory  zone.  The  disturbances  of  sensibility 
observed  after  experimental  destructions  (those  of  Terrier,  and  the 
large  number  performed  in  the  psychiatric  institute  at  Naples)  of 
the  hippocampus  and  limbic  convolution  show  what  extensive 
interlocking  occurs  between  the  olfactory  and  tactile  zones.  On 
the  other  hand,  the  disorders  of  sensibility  consequent  upon  ex- 
perimental and  pathological  lesions  of  the  Rolandic  zone  bring  to 
light  another  interlocking  between  the  motor  zone  and  the  zone  of 
general  sensibility. 

The  question  whether  each  of  the  different  kinds  of  sensibility 
possesses  a different  and  specialized  cortical  centre  has  given  rise 
to  much  discussion.  Several  observations  support  only  the  hypo- 
thesis that  general  and  muscular  sensibility  occupy  the  same  zone 
as  that  of  the  movements,  taken  in  the  sense  of  Boyer  and  Dejerine, 
or  a zone  divisible,  as  I hold,  into  centres  of  greater  functional 
intensity,  surrounded  by  a more  or  less  extensive  zone  of  minor 
functional  intensity  or  of  evolution,  which  comprises  the  base  of  the 
frontal  convolutions,  a part  of  the  ascending  parietal  convolution, 
and  a part  of  the  superior  parietal  lobule.  vShaw  observed  a case 
in  which  a lesion  of  the  centre  for  the  arm  produced  loss  of  muscular 
sense. 

The  observations  of  Dana,  Henschen,  Knapp,  Albertoni,  and 
Brigatti  point  to  the  same  conclusion.  Dejerine  and  E.  Long 
arrive  at  the  same  result  by  different  methods.  Save  for  slight 
differences,  nearly  all  agree  that  the  centre  of  cutaneous  sensibility 
coincides  with  the  motor  zone  in  its  wider  signification,  comprising, 
that  is,  the  feet  of  the  frontal  convolutions  and  the  part  of  the 
parietal  lobules  nearest  to  the  ascending  parietal  (Monakow).  The 
researches  of  Flechsig,  also,  would  lead  us  to  regard  this  same  area 
as  a somaesthetic  zone. 

In  my  opinion,  an  impartial  criticism  of  the  facts  does  not  permit 
of  such  a definite  conclusion.  When  I think  of  the  manv  cases  of 
monoplegia  and  hemiplegia,  with  preservation  of  cutaneous  sen- 
sibility, resulting  from  cortical  or  subcortical  lesions,  of  the  clinical 
cases  and  the  experimental  facts  which  point  to  the  limbic  lobe  as 
a part  of  the  mantle  concerned  in  the  function  of  general  sensi- 
bility, it  seems  to  me  that  we  are  not  warranted  in  excluding  this 
latter  region  from  the  anatomical  field  of  general  sensibility. 


ANATOMICAL  SKETCH  OF  MOTOR  AREAS 


59 


Motor  Paths  and  Centres 

Volitional  movement  is  the  resultant  of  several  concomitant 
forces,  one  of  which  represents  the  fundamental  factor,  whilst  the 
others  prepare,  reinforce,  and  co-ordinate.  The  movement  is 
effected  through  a system  of  fibres  which  go  by  the  name  of  direct 
paths  of  transmission  of  the  volitional  impulses  or  system  of  pyra- 
midal fibres  or  tactile-motor  paths. 

This  system  is  seen  very  distinctly  in  the  spinal  cord,  the  medulla 
oblongata,  the  pons  and  the  cerebral  peduncle,  up  to  the  foot  of  the 
corona  radiata.  From  this  point  to  the  cortex,  which  is  to  be  con- 
sidered as  the  point  of  departure  of  the  said  tract,  its  fibres  spread 
themselves  out,  like  systems  of  superimposed  fans,  intermingling 
and  interlacing  in  various  manners  with  many  others  of  different 
origin  and  function. 

In  the  spinal  cord  the  pyramidal  bundle  appears  at  the  level  of 
the  lumbar  enlargement,  where  it  is  found  in  front  and  to  the  outside 
of  the  posterior  cornua,  just  at  the  periphery  of  the  cord  ; pyramidal 
fibres,  however,  are  found  also  further  down,  even  as  far  as  the 
conus  medulla ris.  Proceeding  upwards  as  a compact  bundle  to  a 
certain  height  in  the  dorsal  region  (not  always  to  the  same  level,  for 
there  are  individual  variations),  it  becomes  pushed  inwards  and 
covered  over  by  the  direct  cerebellar  tract,  at  the  same  time  gradually 
increasing  in  bulk  through  the  fact  that,  from  above  downwards,  the 
pyramidal  tract  gives  off  fibres  to  the  nuclei  of  the  anterior  cornua. 
In  the  cervical  cord  the  pyramidal  bundle  is  contiguous  with  the 
posterior  cornua  behind,  the  limiting  zone  internally,  the  direct 
cerebellar  tract  externally,  and  with  the  tract  of  Gowers  and  the 
mixed  zone,  or  rest  of  the  lateral  column,  in  front. 

Another  portion  of  the  pyramidal  bundle,  somewhat  smaller 
than  the  former,  runs  along  the  internal  aspect  of  the  anterior 
column,  and  is  the  so-called  direct  pyramidal  tract,  or  tract  of 
Tiirk.  The  tract  which  runs  in  the  postero-lateral  column  decus- 
sates at  the  level  of  the  pyramids  with  that  of  the  other  side,  while 
the  tract  of  Turk  proceeds  directly  upwards  towards  the  hemi- 
sphere of  the  same  side.  The  pyramids  of  the  medulla  oblongata  are 
thus  constituted  for  the  most  part  by  the  pyramidal  fibres,  some 
crossed,  some  crossing,  some  which  will  cross,  and  others,  lastly, 
which  ascend  directly  from  the  medulla  to  the  cerebrum.  At  the 
point  of  junction  of  the  medulla  oblongata  with  the  pons  the  decus- 
sation of  the  lateral  pyramidal  tract  is  already  almost  complete, 
and  the  two  portions,  the  stouter  crossed  and  the  smaller  direct, 
having  now  mingled  their  fibres  together,  pursue  their  course  in 
the  inferior  or  ventral  aspect  of  the  pons  close  to  the  median  line. 

From  the  nuclei  of  the  facial  and  hypoglossal  nerves,  just  as 
from  the  cells  of  the  anterior  cornua  of  the  spinal  cord,  there  go  out 


6o 


PSYCHIATRY 


corresponding  bundles  of  fibres  which  we  may  consider  as  short 
branches  of  the  pyramidal  system.  They  form  part  of  the  internal 
arched  fibres  of  the  pons,  and  run  in  the  posterior  half  of  the  pons 
on  the  same  side  as  the  nuclei  from  which  they  take  origin  ; in  the 
anterior  half  of  the  pons,  however,  they  decussate  and  cross  to  the 
other  side. 

In  this  way  the  fibres  of  the  long  pyramidal  bundle  decussate 
at  the  level  of  the  pyramids,  those  of  the  short  pyramidal  bundle 
at  the  level  of  the  anterior  and  middle  part  of  the  pons,  and  those 
of  the  direct  pyrami'dal  bundle,  or  bundle  of  Tiirk,  which  runs  in 
the  anterior  column,  also  decussate  in  the  anterior  commissure. 

Let  us  stop  a little  at  this  point  to  consider  what  remains  to  be 
said  of  this  part  of  the  motor  nervous  system  from  the  cortical  centres 
downwards.  This  will  help  the  rea,der  to  a better  understanding. 

The  cerebral  cortex,  as  apparent  from  the  description  of  the 
functional  regions  which  we  have  already  discussed,  is  a compound 
of  organs  of  different  attributes,  motor,  sensory  and,  let  us  say, 
even  purely  psychic.  The  motor  function  is  fulfilled  by  a somewhat 
extensive  area  embracing  the  Rolandic  fissure,  and  consisting  of  a 
central  and  a surrounding  portion.  The  former  is  represented  by 
the  two  ascending  or  Rolandic  convolutions  and  the  para-Rolandic 
lobule,  and  is  considered  as  an  absolute  motor  zone,  or,  more 
accurately  speaking,  a motor  centre  of  greater  functional  intensity. 
The  periphery  of  the  surrounding  portion  is  not  definitely  limited, 
but  is  continued  all  round  for  a short  distance,  blending  and  fusing 
with  the  neighbouring  areas,  and  has  been  called  the  relative, 
latent,  or  perhaps  preferably  the  evolutive,  motor  zone.  This  zone 
can  be  only  ideally  and  arbitrarily  limited  by  a plane  passing  in 
front  of  the  base  of  the  frontal  convolutions,  anteriorly,  and  through 
the  feet  of  the  parietal  convolutions,  posteriorly. 

The  prolongation  of  these  two  planes  to  the  interhemispheric 
aspect  marks  off  a cortical  field  corresponding  to  the  para-Rolandic 
lobule,  and  forming  also  a part  of  the  motor  zone.  It  is  only  below 
that  the  given  zone  is  distinctly  delimited,  and  this  is  effected  by 
the  fissure  of  Sylvius.  On  this  ample  zone  there  are  found  the  great 
motor  provinces  for  the  muscles  of  the  two  limbs,  the  face,  the 
tongue,  as  well  as  the  trunk,  neck,  larynx,  etc.  (Fig.  24).  On  the 
interhemispheric  aspect,  also,  some  distinguish  several  motor  areas. 
The  movements  of  the  knees  and  legs  would  be  represented  in  the 
para-Rolandic  lobule ; those  of  the  feet  in  the  upper  part  of  the 
quadrate  lobule  ; those  of  the  shoulder  and  head  on  the  upper 
margin  of  the  frontal  convolution,  in  front  of  the  para-Rolandic 
lobule.  All  these  localizations  on  the  internal  aspect  of  the  hemi- 
sphere are  not  of  an  order  so  precisely  defined  as  those  on  the  external ; 
at  least,  they  are  founded  upon  scattered  and  by  no  means  reliable 
observations.  On  the  whole,  such  a decided  delimitation  of  all  the 
motor  and  sensory  areas  is  rather  artificial.  Each  muscular  region  of 


MOTOR  PATHS  AND  CENTRES 


6i 


the  body,  as  well  as  each  muscular  group,  possesses  a centre  of 
greater  functional  intensity  in  the  motor  zone,  properly  so-called, 
but  is  also  more  or  less  represented  in  a more  extensive  zone. 

Furthermore,  they  are  certainly  represented  for  the  most  part 
on  the  motor  zone  of  the  opposite  hemisphere.  This  last  statement 
has  been  amply  demonstrated  by  me  on  experimental  grounds 
(Sulle  comfensazioni  funzionali  della  corteccia  del  cervello,  1883). 

The  centres  of  greater  functional  intensity  are  distinguished  in 
such  a manner  as  to  render  their  topographical  relations  sufficiently 
recognisable  in  man  as  well  as  the  higher  mammals.  To  the  upper 
limb  there  has  been  assigned  the  median  part  of  the  ascending 
frontal  and  ascending  parietal  convolutions  ; to  the  lower  limb, 


Fig.  24. — Cortical  Motor  Zones  for  the  Various  Muscular  Regions  of  the 
Body  and  Sensory  Zones. 


the  upper  extremity  of  the  ascending  parietal,  the  ascending  frontal, 
and  a part  of  the  superior  parietal  lobule  ; to  the  face,  tongue, 
pharynx,  larynx,  etc.,  the  foot  of  the  ascending  frontal,  and  perhaps 
also  a small  part  of  the  inferior  frontal  convolution  (Krause,  Massei, 
Masini).  The  para-Rolandic  lobule  is,  perhaps,  a common  centre 
for  the  two  limbs  of  the  opposite  side,  but  principally  for  the  inferior 
limb. 

Clinical  observations  agree  with  experimental  data  in  showing 
that  such  centres  are  not  absolute  in  the  true  and  strict  sense  of 
the  word.  The  conception  of  monoplegia  is  only  relative,  inso- 
much as  a lesion  of  any  particular  centre  gives  rise  to  paralysis  of 
one  given  muscular  region  principally,  but  not  exclusively.  An 
accurate  examination  of  the  musculature  of  the  whole  side  of  the 
paretic  limb  always  brings  to  light  a certain  degree  of  musculai 
defect  in  other  regions  also,  but,  on  the  other  hand,  paralyses  from 


62 


PSYCHIATRY 


circumscribed  lesions  in  the  cortex  are  pareses  rather  than  true 
paralyses. 

From  the  motor  areas,  or  rather  from  the  pyramidal  cells  which 
they  contain,  nerve  processes  are  given  off,  and  the  fibres  forming 
the  pyramidal  bundle  are  the  continuation  of  these.  In  the  sub- 
cortical white  substance  we  find,  for  a certain  distance,  the  same 
distinction  that  exists  between  the  centres  of  the  various  muscular 
provinces  ; deeper,  the  distinction  is  less  definite,  except  in  the  case 
of  the  larger  bundles,  which  are  fairly  distinct  also  in  the  interna! 
capsule,  as  we  shall  see.  From  my  experimental  and  anatomical 
researches,  however,  I have  elicited  the  fact  that  a certain  number 
of  fibres  constituting  the  subcortical  bundles  of  the  motor  zone, 
which  there  was  reason  to  consider  pyramidal  fibres,  a,bandon  the 
ordinary  path  leading  them  to  the  foot  of  the  corona  radiata  and 
proceed  to  the  corpus  callosum,  where  they  can  be  followed  for  a 
certain  distance  by  the  method  of  experimental  degenerations. 
This  small  bundle,  whose  situation  D’Abundo  and  myself  were 
unable  to  define  throughout  its  whole  course,  certainly  goes,  how- 
ever, to  take  part  in  the  constitution  of  the  pes  pedunculi  of  the 
other  side,  where,  in  some  of  our  experiments,  we  found  degener- 
ated fibres  ; it  then  blends  with  the  pyramidal  fibres  of  the  other 
hemisphere,  and  so  reaches  the  pyramid,  where  it  undergoes  a 
second  decussation,  passing  into  the  postero-lateral  bundle  of  the 
half  of  the  spinal  medulla,  homonymous  with  the  cerebral  hemi- 
sphere from  which  it  is  derived.  Hence  we  are  induced  to  admit 
a second  order  of  pyramidal  fibres,  possibly  collateral,  which,  by 
their  twofold  decussation,  the  first  in  the  corpus  callosum  and  the 
second  at  the  level  of  the  pyramids,  return  to  the  side  of  the  spinal 
medulla  homonymous  with  the  hemisphere  from  which  they  took 
origin.  With  this  conception  we  can  understand  better  the  de- 
generation of  the  crossed  pyramidal  bundle  on  both  sides  of  the 
spinal  medulla  as  we  observed  it  both  in  man  and  in  dogs — in  the 
former  as  the  result  of  gross  destructive  foci  in  the  motor  centres 
or  the  subcortical  pyramidal  paths,  in  the  latter  as  the  result  of 
extirpation  of  the  motor  zone. 

The  passage  of  a certain  number  of  pyramidal  fibres  into  the 
corpus  callosum,  and  their  redecussation  at  the  level  of  the  pyramids, 
detracts  in  no  wise  from  what  has  been  already  laid  down  concerning 
the  direct  pyramidal  bundle,  seeing  that  I have  been  able  to  prove 
from  a series  of  experiments  that  when,  as  the  result  of  excitation 
of  the  exposed  motor  zone,  movements  occur  on  the  same  side  as 
the  excited  hemisphere,  these  do  not  all  disappear,  but  merely 
become  limited  on  section  of  the  anterior  portion  of  the  corpus 
callosum.  On  the  other  hand,  the  observation  of  nerve  processes 
(collaterals)  belonging  to  the  pyramidal  cells  and  proceeding  to  the 
corpus  callosum  (Marchi),  and  the  researches  of  Brown-Sequard, 
which  should  have  led  to  the  admission  of  the  excitability  of  the 


MOTOR  P^ATHS  AND  CENTRES 


63 


corpus  callosum,  agree  with  those  very  conclusive  results  of  mine 
before  mentioned,  and  warrant  us  in  considering  it  probable  that  the 
corpus  callosum  is  one  of  the  indirect  paths  of  the  motor  fibres. 


zm,  Motor  zone ; nc,  caudate  nucleus  ; to,  optic  thalamus ; nl,  lenticular 
nucleus  ; cc,  corpus  callosum  ; ci,  internal  capsule  ; fdpp,  degenerated  fibres  in  the 
pes  pedunculi  of  the  side  opposite  to  the  injured  hemisphere  ; p,  pyramid  ; fpl, 
lateral  or  crossed  pyramidal  bundle  ; fpd,  direct  pyramidal  bundle  ; fvpl,  lateral 
pyramidal  bundle  after  redecussation. 


Fig.  25  well  represents  the  course  of  such  fibres,  partly  demonstrated, 
partly  assumed. 

An  almost  identical  hypothesis  was  put  forward  by  Tenchini  in 
referring  to  a work  of  Ugolotti  at  the  congress  of  anatomists  held  in 
the  summer  of  1901  at  Pavia,  on  the  ground  that  in  some  cases  of 


64 


PSYCHIATRY 


destructive  foci  of  the  nuclei  of  the  motor  zone  he  discovered  re- 
decussation of  some  of  the  degenerate  fibres  passing  to  the  pyramid 
of  the  same  side  as  the  injured  hemisphere.  Only,  it  is  strange  that 
he  has  shown  ignorance  of  the  experimental  facts  and  anatomical 
researches  which  fourteen  years  ago  enabled  D’Abundo  and  myself 
to  formulate  a similar  hypothesis — the  only  one,  indeed,  which 


t 


Fig.  26. — Horizontal  Section  of  the  Left  Hemisphere  through  the  Basal  ■ 
Ganglia  and  the  Internal  Capsule.  ; 

c,  Caudate  nucleus  ; nl,  lenticular  nucleus  ; to,  optic  thalamus  ; cl,  claustrum  ; | 
canc,  tail  of  the  caudate  nucleus  ; i,  2,  3,  internal  middle  and  external  nuclei  of  | 
the  lenticular  nucleus  ; Imi,  Ime,  internal  and  external  medullary  laminae  ; ci,  ^ 
posterior  segment  of  the  internal  capsule  ; ei,  anterior  segment  of  the  internal  capsule  ; j 
qci,  genu  of  the  internal  capsule  ; ce,  external  capsule  ; R,  island  of  Reil.  j 


seems  to  give  a really  plausible  interpretation  of  the  bilateral  de- 
generation of  the  [)yramidal  bundle  following  a mono-hemispheric 
lesion,  taking  into  account,  as  it  does,  the  degenerate  fibres  dis- 
covered by  Marchi,  Algeri,  and  others  in  the  corpus  callosum  and 
in  the  pes  pedunculi,  on  the  side  opposite  to  that  of  the  hemispheric 
lesion,  and  those  passing,  according  to  Ugolotti,  from  the  opposite 
to  the  homonymous  pyramid.  Besides,  these  fibres  would  be  the 
paths  by  which  excitation  of  a hemisphere  produces  bilateral  move- 
ments, since  it  now  appears  demonstrated  that  at  least  a part  of  the 


MOTOR  PATHS  AND  CENTRES 


65 


fibres  of  the  direct  bundle  of  Tiirk  also  undergo  decussation  in  the 
anterior  commissure  of  the  spinal  cord. 

The  greater  part  of  the  pyramidal  bundle,  however,  continues  its 
way  into  the  hemisphere,  and,  gathering  itself  increasingly  into  a 
compact  bundle,  constitutes  the  internal  capsule. 

This  is  found  as  a stiip  of  white  substance  enclosed  between  the 
nuclei  of  the  base,  and  forming  an  angle  pointing  inwards  (Fig.  26). 
It  is  consequently  divided  into  two  distinct  segments — an  anterior, 
included  between  the  caudate  and  lenticular  nuclei,  and  a posterior, 
between  the  lenticular  nucleus  and  the  optic  thalamus,  besides  a 
sub-  or  extra-lenticular  part.  The  meeting-point  of  the  two  segments 
forms  an  obtuse  angle,  and  goes  by  the  name  of  the  ‘genu’  of  the 
capsule.  Looked  at  from  above  downwards,  it  is  divisible  into 
a thalamic  portion,  properly  so-called,  and  a subthalamic  portion. 
The  former  is  comprised  between  the  nuclei;  the  subthalamic 
portion,  as  is  easily  understood,  forms  a part  of  the  posterior 
segment,  the  particulars  of  which  we  shall  investigate  more  fully. 

In  this  part  of  the  central  nervous  system  also  it  is  possible  to 
distinguish,  by  the  help  of  clinical  observations  and  experimental 
researches,  areas  of  diverse  physiological  function  corresponding  in 
a certain  manner  to  the  functional  differences  of  the  cortex  of  the 
brain.  The  anterior  segment  is  formed  principally  of  lenticulo- 
caudate  fibres  and  of  fibres  with  a horizontal  and  oblique  direction, 
coming  from  the  cortex,  and  almost  all  ending  in  the  optic  thalamus,' 
of  which  they  form  the  anterior  peduncle  (Dejerine).  According  to 
the  researches  of  Dejerine,  not  only  does  it  contain  no  sensory  fibres, 
but  even  motor  fibres  (Charcot)  are  absent. 

According  to  some  authorities,  this  tract  of  the  capsule  would 
contain  also  the  projection  bundle  passing  from  the  frontal  lobe  to 
the  optic  thalamus  and  pons  varolii.  It  certainly  contains  cortico- 
thalamic fibres  of  projection,  but  it  still  remains  to  be  shown  that  it 
affords  passage  to  fibres  proceeding  directly  from  the  frontal  lobe 
to  the  pons.  In  fact,  while  with  Weigert’s  method  I have  observed 
degenerated  fibres  in  the  anterior  segment  of  the  capsule,  after 
extirpation  of  the  frontal  lobe,  such  degeneration  is  entirely  absent 
m brains  treated  with  Marchi’s  method. 

The  existence  of  this  large  bundle,  which  I have  not  succeeded  in 
demonstrating,  and  which  I consider  hypothetical,  has  been  re- 
asserted on  all  sides,  and  in  recent  times  more  especially  by  Bech- 
terew,  as  is  clearly  set  forth  in  his  diagram  (Fig.  27).  As  regards 
this  bundle,  it  is  well  to  come  to  some  understanding.  If  by 
It  we  wish  to  indicate  with  Dejerine,  and  more  particularly  with 
V . Gehuchten,  the  fibres  of  projection  of  the  pre-Rolandic  motor  zone 
(latent,  evolutive),  which  become  blended  with  the  rest  of  the  pyra-  ^ 
midal  bundle  m passing  through  the  posterior  segment  of  the  internal 
capsule,  I quite  agree,  since  in  one  case  which  came  under  my  obser- 
vation—a case  of  mutilation  of  the  frontal  lobe  a little  behind  the- 

5 


66 


PSYCHIATRY 


prefrontal  sulcus — I found  a certain  degree  of  degeneration  in  the 
genu  and  in  the  anterior  tract  of  the  lenticulo-optic  segment  of  the 
internal  capsule.  But  if  we  are  to  understand,  as  previously 
asserted  on  insufficient  grounds,  a bundle  of  fibres  coming  from  the 
prefrontal  lobe,  and  passing  through  the  anterior  segment  of  the 
capsule  to  reach  the  innermost  bundle  of  the  pes  pedunculi,  and 
hence  the  pons,  as  Bechterew  states  in  his  treatise,  I must  state  in 
opposition  that  a considerable  number  of  observations  of  my  own, 
based  on  the  examination  of  a large  number  of  serial  sections  from 
the  brains  of  monkeys  that  had  suffered  mutilation  of  the  frontal 
lobes,  show  integrity  of  the  internal  capsule,  and  of  the  pes  pedunculi 
throughout  its  whole  extent.  There  are  no  relations,  either  direct  or 


Fig.  27. — Scheme  of  the  Topographical  Distribution  of  the  Bundles  of 
Fibres  in  the  Internal  Capsule.  (After  Bechterew.) 

nc,  Nucleus  caudatus  ; gp,  globus  pallidus  ; pt,  putamen  of  the  lenticular  nucleus  ; 
i,  fibres  going  direct  to  the  anterior  segment  of  the  thalamus  ; 2,  fibres  from  the 
frontal  lobe  to  the  pons  (?)  ; 3,  paths  of  the  fibres  of  the  motor  nerves  of  the  brain  I 
(facial  and  hypoglossal)  ; 4,  pyramidal  paths  ; 5,  sensory  paths  ; 6,  paths  from  the  > 
temporo-occipital  lobe  to  the  pons.  : 

I 

indirect,  between  the  prefrontal  lobe  and  the  pes  pedunculi ; they  1 
can  hardly  be  admitted  by  the  slow  method  of  degeneration  ■ 
(Weigert,  Pal)  in  the  anterior  tract  of  the  internal  capsule,  and  if 
any  degenerate  fibres  are  discovered  there,  they  are  in  all  prob- 
ability fronto-thalamic  (Bianchi). 

In  the  genu  and  a small  tract  of  the  posterior  segment  the  fibres 
are  mostly  those  coming  from  the  cortical  centres  for  the  face  and 
tongue.  They  come  from  the  Rolandic  and  frontal  portions  of  the 
operculum  (foot  of  the  inferior  frontal  and  of  the  Rolandic  convolu- 
tions), pass  through  the  genu  of  the  capsule,  and  arrange  them- 
selves in  the  inner  segment  of  the  pes  pedunculi.  According  to 
Bechterew,  the  fibres  of  the  median  accessory  lemniscus  also  pass  > 
through  this  tract  of  the  capsule.  The  posterior  or  lenticulo-optic  | 


MOTOR  PATHS  AND  CENTRES 


67 

segment,  then,  presents  essential  features  of  its  own.  In  fact,  if  in 
the  imagination  we  divide  this  segment  into  two  parts,  an  anterior 
and  a posterior,  we  will  be  able  to  assign  with  certainty  to  the  former 
the  signification  of  paths  of  the  motor  fibres  for  the  limbs  of  the  oppo- 
site side  (pyramidal  system),  and  to  the  latter  the  signification  of 
paths  of  the  sensory  fibres  for  the  opposite  side  of  the  body 
(thalamic  and  thalamo-cortical  system).  We  have  already  said  that 
a portion  of  the  sensory  fibres  mingles  with  the  pyramidal  fibres  in 
the  capsule. 

More  recent  studies  have  demonstrated  the  fact  that  the  pyra- 
midal fibres  in  these  parts  of  the  posterior  segment  of  the  capsule  do 
not  wholly  intermingle.  Dejerine,  in  eleven  cases  of  cortical  lesions 
followed  by  secondary  degenerations  in  the  capsule  and  in  the  pes 
pedunculi,  succeeded  in  determining  more  clearly  than  any  other 
the  position  of  the  degenerated  portion  of  the  pyramidal  fibres  in  the 
capsule.  In  cases  of  lesions  in  the  middle  part  of  the  two  ascending 
convolutions,  and  in  the  posterior  extremity  of  the  second  frontal, 
the  degeneration  in  the  above-mentioned  thalamic  region  occupied 
the  middle  third  of  the  posterior  segment  ; the  anterior  and  the 
retro-lenticular  segments  of  the  capsule  were  intact.  In  the  pes 
pedunculi  the  degeneration  occupied  the  second  inner  quarter.  In 
four  cases  of  a localized  lesion  of  the  superior  third  of  the  Rolandic 
region  and  the  foot  of  the  first  frontal  convolution  the  degeneration 
occupied,  in  the  thalamic  region,  the  posterior  part  of  the  posterior 
segment,  which,  further  behind,  contained  several  normal  fibres, 
while  in.  the  inferior  thalamic  region,  in  consequence  of  the  arrival 
of  the  bundle  of  Turk,  the  degenerated  tract  was  found  displaced 
further  forwards  ; the  posterior  fifth  of  that  segment  was  intact. 
In  the  peduncle  the  zone  of  degeneration  occupied  the  third  quarter 
of  the  pes,  counting  from  within  outwards. 

In  two  cases  of  localized  lesion  of  the  extreme  upper  portions  of 
the  Rolandic  convolutions,  including  the  paracentral  lobule  and  the 
anterior  extremity  of  the  parietal  lobe,  the  zone  of  degeneration 
occupied  the  hindmost  portion  of  the  thalamic  segment,  while  in  the 
subthalamic  region,  in  consequence  of  the  appearance  of  the  normal 
bundle  of  Tiirk,  the  degenerated  zone  was  pushed  a little  in  front. 
The  retro-lenticular  segment  was  normal.  In  the  pes  pedunculi  the 
degeneration  was  limited  to  the  inside  of  the  bundle  of  Tiirk,  and 
consequently  was  seen  as  a zone  a little  more  external  to  that  occu- 
pied in  the  preceding  cases,  and  corresponding  exactly  to  the  fourth 
fifth  of  the  pes,  reckoning  from  within  outwards. 

The  posterior  segment  of  the  capsule,  properly  speaking,  forms  by 
itself  the  inner  four-fifths  of  the  pes  pedunculi,  and  has  assigned  to  it, 
as  already  seen,  the  retro-lenticular  portion,  composed  of  sensory 
fibres,  horizontal  fibres  going  to  the  pulvinar,  others  going  to  the 
external  geniculate  body  to  form  the  stratum  zonale,  and  others, 
again,  going  to  the  anterior  quadrigeminate  body.  Through  this 

5—2 


68 


PSYCHIATRY 


last  tract  of  the  postero-inferior  part  of  the  posterior  segment  of  the 
capsule  there  pass  likewise  the  hbres  constituting  the  so-called 
bundle  of  Tiirk  ; these  arise  from  the  cortex  of  the  first  and  second 
temporal  convolutions  and  also  from  the  occipital  lobe,  pass  through 
the  tract  of  the  capsule,  marked  in  Fig.  27  by  the  number  6,  locate 
themselves  at  the  outermost  margin  of  the  pes  pedunculi,  and  become 
lost  in  the  pons.  The  function  of  this  bundle  is  still  unknown. 

From  the  capsule  the  motor  fibres  next  pass  into  the  pes  pedun- 
culi, preserving  the  same  order  of  distinction  that  has  been  noted  in 
the  capsule  itself.  On  the  pes  pedunculi,  however,  one  can  distin- 
guish a more  internal  bundle,  which,  it  is  held,  might  be  constituted 
by  fibres  proceeding  from  the  frontal  lobe  to  the  pons  ; it  is,  however, 
of  very  obscure  origin  (Fig.  23,  / f).  I have  never  found  it  degene- 
rated in  any  of  the  numerous  sections  of  the  brains  of  monkeys  from 
which  I had  previously  extirpated  the  frontal  lobes.  In  all  prob- 
ability it  corresponds  to  the  peduncular  path  for  fibres  coming  from 
the  foot  of  the  second  and  third  frontal  convolutions,  and  from  the 
facial,  hypoglossal,  and  pharyngeal  nerve  centres.  Next  come  the 
peduncular  divisions  of  the  pyramidal  bundle,  one  immediately  after 
the  other,  preserving  the  disposition  already  mentioned. 

The  pyramidal  fibres  of  the  pes  pedunculi  become  somewhat 
scattered  in  their  passage  through  the  pons.  The  middle  bundle  is 
very  distinct  and  fairly  compact,  and  runs  close  to  the  inferior  aspect 
of  the  pons,  above  the  external  arcuate  fibres  and  near  to  the  raphe  ; 
the  fibres  given  off  from  the  pyramidal  bundle  to  the  nuclei  of  the 
cranial  motor  nerves  are  found  higher  up. 

While  the  pyramidal  fibres  of  the  limbs  run  in  the  half  of  the  pons 
corresponding  to  the  hemisphere  from  which  they  originate,  those  of 
the  facial  and  the  other  cranial  motor  nerves  (hypoglossal,  a part  of 
the  vagus,  the  masticatory,  the  facial)  decussate  higher  up,  so  that 
in  the  posterior  half  of  the  pons  we  find  the  pyramidal  bundle  for 
the  limbs  of  the  homonymous  hemisphere,  and  the  bundle  of  the 
facial  and  the  other  cranial  motor  nerves  belonging  to  the  other  hemi- 
sphere. The  pyramidal  bundle  for  the  limbs  constitutes  the  pyramid 
of  the  medulla  oblongata,  at  which  level  the  decussation  of  its  fibres 
becomes  evident  for  a greater  or  less  extent. 

Considering  now  the  relations  set  up  between  one  pyramid  and 
the  spinal  medulla  after  the  decussation,  we  can  assert  that  the 
pryamid  transmits  to  the  spinal  medulla — (i)  the  crossed  pyramidal 
fibres  coming  from  the  opposite  hemisphere  ; (2)  the  crossed  pyra- 
midal fibres  coming  from  the  homonymous  hemisphere,  and  under- 
going their  first  decussation  in  the  corpus  callosum — homolatcral 
fibres  (these  and  the  preceding  are  situated  in  the  postero-lateral 
columns  of  the  spinal  medulla)  ; (3)  the  direct  fibres  passing  from 
the  hemisphere  of  one  side,  and  even  perhaps  simply  from  the 
pyramid  (the  bundle  of  Pitres,  more  fully  studied  recently  by  Roth- 
mann),  without  decussation,  into  the  spinal  medulla,  where  they  run 


MOTOR  PATHS  AND  CENTRES 


69 


in  the  anterior  column  constituting  the  bundle  of  Tiirk,  or  direct 
bundle.  As  before  mentioned,  the  fibres  of  this  bundle,  in  the  opinion 
of  some — e.g.,  Van  Gehuchten  — decussate  completely  in  the 
anterior  commissure.  According  to  Lenhossek,  no  such  decussation 
exists,  while  Ziehen  admits  a partial  decussation,  and  holds  that  the 
fibres  subserve  the  muscles  of  the  trunk,  and  that  in  consequence 
each  hemisphere  is  in  connection  with  the  muscles  of  both  sides  of 
the  trunk. 

All  these  motor  strands  are  interrupted  by  the  cells  of  the 
anterior  cornua  of  the  spinal  medulla,  where  the  pyramidal  fibres, 
or,  if  otherwise  preferred,  the  cortico-pyramidal  neurones,  ter- 
minate ; the  axis-cylinder  prolongations  of  the  cells  of  the  anterior 
cornua  then  give  origin  to  the  fibres  of  the  anterior  roots. 

The  cerebrum,  however,  is  in  connection  with  the  spinal  medulla 
by  means  of  another  class  of  fibres,  also  motor,  but  secondary, 
inasmuch  as  they  reach  the  spinal  medulla  from  the  cerebellum. 

These  are  the  so-called  cerebello-motor  paths,  and  two  orders 
of  neurones  are  herein  concerned  ; the  first  goes  from  the  cerebrum 
to  the  cerebellum  by  means  of  the  middle  cerebellar  peduncle  ; the 
second  from  the  cerebellum  to  the  anterior  cornua  of  the  spinal 
medulla,  by  means  of  the  same  peduncle.  The  former,  in  its  turn, 
comprises  two  kinds  of  neurones  ; one  goes  from  the  cortex  of  the 
cerebrum  to  the  gray  nuclei  of  the  pons  of  the  same  side,  and  the 
other  arises  from  the  gray  nuclei  of  the  pons,  decussates  in  the  raphe 
with  the  homonymous  one  of  the  other  side,  and  passes  across  the 
middle  cerebellar  peduncle  to  the  cerebellar  hemisphere  of  the  oppo- 
site side.  The  fibres  of  the  first  type  descend  from  the  cerebrum  to 
the  pons  (V.  Gehuchten),  which  explains  why  experimental  destruc- 
tions of  the  cerebellum  have  not  produced  degeneration  of  them  on 
that  side  of  the  pons  (Vejas,  Mingazzini). 

The  question  of  the  exact  part  of  the  cerebral  mantle  that  fur- 
nishes the  cortico-pontine  fibres  has  given  rise  to  a great  deal  of  dis- 
cussion. In  the  past  it  has  been  held,  without  any  proof,  that  the 
fibres  in  question  came  from  the  cortex  of  the  frontal  lobe  ; the 
researches  of  Zacher,  Dejerine,  Flechsig,  as  well  as  my  own  {Le 
degener azioni  discendenti  endoemisferiche  seguite  alia  estirpazione 
dei  lohi  frontali,  Annali  di  Nevrologia,  1895),  although  contradicted 
by  the  more  recent  ones  of  Rutishauser,  demonstrated  with  sufficient 
clearness  that  it  is  not  the  prefrontal  lobe  which  sends  the  fibres  to  the 
pons.  It  can  hardly  be  admitted  that  such  fibres  come  from  the 
evolution  motor  zone — that  is  to  say,  from  the  base  of  the  second  and 
third  frontal  convolutions,  where  they  join  the  ascending  frontal 
convolution. 

They  pass  through  the  genu  and  the  posterior  segment  pf  the 
capsule,  partly  mixed  with  the  other  motor  fibres,  and  occupy  the 
inner  segment  of  the  pes  pedunculi,  whence  they  proceed  to  the  gray 
substance  of  the  pons. 


70 


PSYCHIATRY 


The  nerve-prolongations  of  the  cells  of  the  gray  substance  of  the 
pons  nearly  all  decussate,  and  constitute  the  fronto-cerebellar  fibres 
which  proceed  to  the  cortex  of  the  cerebellum.  All  the  fibres  going 
from  the  cerebral  to  the  cerebellar  cortex  constitute  the  first  order, 
using  Van  Gehuchten’s  term,  or,  in  other  words,  the  upper  portions  of 
the  secondary  tacto-motor  path. 

The  course  pursued  by  the  fibres  going  from  the  cerebellum  to 
the  cells  of  the  anterior  cornua  of  the  spinal  medulla  is  not  so  well 
known,  and  we  have  even  little  or  no  knowledge  of  the  part  of  the 
cerebellum  from  which  they  take  origin.  According  to  some,  they 
descend  through  the  inferior  cerebellar  peduncle  to  the  lateral 
column  of  the  same  side  (Marchi,  Thomas)  ; or  they  are  represented 
by  two  neurones — one  cerebello-olivar,  the  other  olivo-medullary 
(Kolliker) — which  arrive  at  the  medulla  by  means  of  the  middle 
cerebellar  peduncle  and  the  pons  (Cajal),  and  have  their  primary 
origin  in  the  dentate  nucleus  (Thomas).  These  are  the  principal 
theories.  What  is  important  is  that,  besides  the  corticospinal  paths 
(direct),  it  is  probable  that  there  also  exist  cortico-ponto-cerehello- 
spinal  paths  (indirect).*  These  two  kinds  of  fibres,  the  cortico- 
spinal and  the  cortico-cerebello-spinal,  proceed  together  from  the 
cortex  as  far  as  the  pons,  where  they  separate,  each  to  pursue  its  own 
course. 

A lesion  limited  to  one  of  the  two  orders  of  fibres  leaves  active 
the  influence  of  the  will  upon  the  spinal  medulla,  and  hence  on  the 
muscles.  In  this  case  there  will  not  be  a true  paralysis.  If  the 
indirect  cerebello-spinal  paths  are  injured  inco-ordination  results  ; 
if,  instead,  the  pyramidal  or  cortico-spinal  paths  are  injured  we  have 
muscular  spasm,  as  in  Little’s  disease.  In  both  cases  a true  para- 
lysis will  be  absent.  If,  however,  both  are  injured,  there  will  be  a 
true  paralysis,  as  happens  in  lesions  of  the  cortex,  of  the  internal 
capsule,  and  in  transverse  lesions  of  the  spinal  cord. 

Associative  Paths 

The  efflcacious  working  of  the  various  cortical  zones  would  not 
be  conceivable,  nor  would  their  complex  products  and  contributions 
be  obtained  if  the  innumerable  workers  which  each  of  them  employs 
in  their  respective  and  manifold  laboratories  were  not  in  relation 
with  one  another,  or,  in  other  words,  if  the  various  functional  zones 
were  not  strictly  co-related  by  numerous  paths,  and,  above  all,  if 
they  were  not  in  harmony  throughout  every  movement  of  psychic 
life,  or  were  not  all  connected  with  the  zone  concerned  in  the 
synthesis  of  cortical  work — that  is  to  say,  with  the  frontal 
lobes. 

* I have  said  ‘ it  is  probable,’  for,  in  spite  of  the  numerous  statements 
in  support  thereof,  admirably  summarized  by  Soury,  the  motor  nature  of  the 
cortico-ponto-cerebellar  paths  is  far  from  being  conclusively  demonstrated. 


ASSOCIATIVE  PATHS 


71 


When  we  examine  under  the  microscope  a section  of  cerebral 
cortex  prepared  after  the  method  of  Weigert  or  Pal,  there  may  be 
seen  among  the  layers  of  cells,  especially  the  deeper  ones,  or  in  the 
subcortical  substance,  not  only  bundles  of  fibres  of  projection, 
which  tend  to  reunite  like  the  ribs  of  a fan,  but  also  a dense  network 
of  myelinated  fibres,  some  short,  some  long,  but  all  pursuing  the 
most  diverse  directions,  intercrossing  in  every  direction  and  forming 
a very  dense  reticulum,  as  depicted  in  Fig.  28. 

This  network  of  fibres,  running  in  the  most  diverse  directions, 
gives  at  once  an  idea  of  the  infinite  anatomical  relations  existing 
between  the  various  regions  of  the  brain. 

Apart  from  what  will  be  said  of  the  intimate  structures  of  the 


Fig.  28. — Network  of  Myelinated  Nerve  Fibres  in  the  Cerebral  Cortex. 


cerebrum,  it  is  requisite  at  this  point,  in  so  far  as  the  object  and 
practical  nature  of  this  work  permit,  to  speak  more  especially  of 
some  bundles  which  establish  certain  long  and  direct  associative 
paths  between  distant  cerebral  provinces,  and  a knowledge  of  which 
facilitates  the  interpretation  of  the  facts  that  we  must  dwell  upon  in 
the  ensuing  chapters. 

We  will  not  take  up  time,  then,  in  describing  the  long  and  short 
associative  fibres,  which,  assuming  a U-like  curve  (arched  fibres  of 
Arnold),  extend  between  one  convolution  and  the  adjoining,  em- 
bracing the  intervening  sulcus  and  establishing  relations  now 
regarded  as  indispensable  between  the  two  convolutions. 

We  shall  occupy  ourselves  only  with  those  bundles  which  modern 
morphology  has  more  dehnitely  emphasized,  and  an  acquaintance 


72 


PSYCHIATRY 


with  which  facilitates  immeasurably  the  interpretation  of  both  the 
normal  and  pathological  phenomena  of  cerebralization. 

Among  the  systems  of  association  we  can  include  the  corpus 
callosum,  the  anterior  commissure,  and  the  transverse  fornix  of 
Forel. 

Of  the  anterior  commissure  we  have  spoken  sufficiently  in  the 
chapters  dealing  with  the  olfactory  apparatus  (Fig.  ii). 

The  corpus  callosum  is  a commissure,  or  a system  of  inter- 
hemispheric  associations,  and  is  divisible  into  several  parts — the 
knee,  the  beak,  the  body,  and  the  pad. 

The  beak  (rostrum)  of  the  corpus  callosum  is  composed  of  fibres 
from  both  sides,  which  decussate  and  establish  relations  between  the 
orbital  portions  of  the  frontal  convolutions  of  either  side. 

The  knee  i^genu)  is  formed  of  fibres  which  come  from  the  external, 
orbital,  and  internal  aspects  of  the  frontal  lobe,  and  converge  towards 
the  antero-external  amgle  of  the  lateral  ventricle.  According  to  some 
(Schnopfhagen),  the  genu  would  also  contain  fibres  of  the  arcuate 
bundle,  reuniting  the  frontal  lobe  of  one  side  with  the  temporal  lobe 
of  the  other.  We  shall  see  directly  how  improbable  is  such  a hypo- 
thesis. 

The  body  (^corpus)  of  the  corpus  callosum  is  formed  of  fibres 
coming  from  the  whole  external  face  of  the  frontal  lobe,  from  the 
Rolandic  convolutions,  from  the  whole  parietal  lobe,  from  the  pos- 
terior part  of  the  temporal  lobe,  from  the  insula  through  the  medium 
of  the  external  capsule,  and  from  the  precuneus.  The  fibres  com- 
posing it  put  into  relation  with  one  another,  not  only  symmetrical, 
but  also  asymmetrical  regions  of  the  two  hemispheres. 

The  pad  may  be  divided  into  three  parts — a superior,  continuous 
with  the  body ; an  intermediate  (or  posterior  extremity  of  the  corpus 
callosum,  called  also  posterior  genu)  ; and  an  inferior  or  recurved 
portion,  called  aJso  the  splenium.  The  intermediate  (or  posterior) 
and  the  inferior  parts  are  composed  of  fibres  coming  from  the  infero- 
internal  and  the  external  aspects  of  the  occipital  lobe,  forming  the 
forceps  major  and  forceps  minor. 

The  true  endo-hemispheric  associative  bundles  are  those  which 
establish  associative  relations  between  cortical  provinces  of  the  same 
hemisphere.  These  we  shall  describe  below  as  briefly  as  possible. 

The  cingulum  belongs  to  the  system  of  the  rhinencephalon, 
forms  a part  of  the  white  substance  of  the  limbic  lobe,  and,  as  it 
follows  the  direction  of  the  latter,  is  likewise  arched.  It  takes 
origin  from  the  fronted  lobe,  covers  the  genu,  body,  and  splenium  of 
the  corpus  callosum,  curves  round  into  the  inferior  limbic  lobe,  and, 
crossing  the  hippocampus,  reaches  the  extremity  of  the  uncinate 
convolution.  It  receives  fibres  from  all  the  cerebral  regions  which 
it  traverses,  and  especially  from  the  first  frontal  convolution,  the 
paracentral  lobule,  the  precuneus,  the  cuneus,  the  lingual  and  fusi- 
form lobules,  and  the  temporal  pole,  and  gives  off  its  own  fibres  to 


ASSOCIATIVE  PATHS 


73 


the  same  parts.  It  is  formed  mostly  of  short  fibres,  or,  at  least, 
fibres  not  so  long  as  the  whole  limbic  lobe.  In  fact,  Beevor  main- 
tains that  it  is  formed  of  at  least  three  associative  bundles — an 
anterior,  a horizontal,  and  a posterior.  The  anterior  would  put  the 
anterior  perforated  space  and  the  inner  olfactory  root  (its  cortical 
centre)  into  relation  with  the  anterior  extremity  of  the  frontal  lobe  ; 
the  horizontal  bundle  would  bring  the  external  and  internal  aspects  of 
the  frontal  lobe  into  relation  with  the  first  limbic  convolution  ; the 
posterior  bundle,  occupying  the  region  of  the  hippocampus,  unites 


C,  Cuneus  ; Cing(a),  anterior  bundle  of  the  cingulum  ; Cing(h)J horizontal  or 
superior  bundle  of  the  cingulum  ; Cing(k),  posterior  bundle  of  the  cingulum  ; Cing(p), 
inferior  bundle  of  the  cingulum  ; cm,  calloso-marginal  sulcus  ; cmb  vertical  branch  of 
the  calloso-marginal  sulcus  or  ramus  subpariet. ; Fbi,  internal  basal  bundle  of  Burdach ; 
Fli,  inferior  longitudinal  bundle  ; Fus,  fusiform  lobule  ; H(L),  hippocampus 

K,  calcarine  fissure  ; L,  convolution  of  the  corpus  callosum ; Lg,  lingual  lobule  ; 
mF,  internal  aspect  of  the  first  frontal  convolution  ; ot,  collateral  sulcus  ; Parc, 
paracentral  lobule  ; Po,  parieto-occipital  fissure  ; PrC,  praecuneus  ; so,  supra-orbital 
sulcus  of  Broca  ; strk,  calcarine  layer  ; Tg,  third  temporal  convolution  ; Th,  optic 
thalamus.  (From  Dejerine.) 

the  hippocampus  and  the  point  of  the  temporal  lobe  to  the  lingual 
and  fusiform  lobules. 

I have  found  many  degenerated  fibres  in  the  cingulum,  and  traced 
them  from  before  baxkwards  for  a long  distance,  after  extirpation  of 
the  frontal  lobe  {vide  Recerche  suite  degenerazioni  discendenti  seguite 
air  estirpazione  del  loho  frontale,  Bianchi). 

Uncinate  Bundle. — This  is  composed  of  fibres  arising  from  the 
orbital  convolutions  of  the  frontal  lobe,  from  the  anterior  perforated 
substance,  and  from  the  orbital  and  external  aspects  of  the  third 
frontal  convolution.  Taking  a more  or  less  markedly  curved  course, 
they  turn  round  the  end  of  the  Sylvian  fissure,  and  run  in  a direction 


Qin^(p) 
Fig.  2c. 


74 


PSYCHIATRY 


from  behind  forwards  towards  the  extremity  of  the  temporal  lobe, 
some  of  the  fibres  traversing  the  anterior  part  of  the  external 
capsule  (Fig.  30). 

In  my  opinion,  the  uncinate  bundle  is  only  one  part  of  a system 
of  fibres  commencing  at  the  inferior  and  external  aspects  of  the 
frontal  lobe,  uniting  together  into  a more  or  less  compact  bundle, 
and  continued,  in  a more  scattered  form,  into  a system  of  fibres, 
some  of  which  are  projected  from  the  frontal  and  Rolandic  opercu- 
lum into  the  outermost  capsule  {capsula  extrema"^),  while  others 
pass  through  the  external  capsule,  whence,  curving  under  the  insula 
and  forming  also  a kind  of  U upside  down,  they  reach  the  temporal 
lobe,  and,  in  preference,  the  first  temporal  convolution. 

The  Superior  Longitudinal  or  Arcuate  Bundle. — This  is  seen 


Fig.  30. — Scheme  of  the  Chief  Bundles  of  Association. 


on  the  external  aspect  of  the  centrum  ovale,  close  to  the  cortical 
gray  substance,  in  a vertical  fronto-occipital  section.  According 
to  Meynert,  its  fibres  would  bring  the  Rolandic  operculum  and  that 
of  the  third  frontal  convolution,  besides  the  external  aspect  of  the 
frontal  lobe,  into  relation  with  the  external  aspect  of  the  temporo- 
occipital  region.  According  to  Schnopfhagen,  it  would  be  a crossed 
bundle,  an  extension  of  the  corpus  callosum,  and  would  put  in  rela- 
tion the  temporo-occipital  lobe  of  one  side  with  the  frontal  lobe  of 
the  opposite.  This  last  opinion  is  not  confirmed  by  my  observa- 
tions, inasmuch  as,  in  a long  series  of  sections  of  brains  which  had 
undergone  mutilation  of  the  frontal  lobes,  I have  been  able  to  follow 
a small  fasciculus  of  the  arcuate  bundle  which  degenerates  on  the 
same  side  ; this  fa.sciculus  is  projected  into  the  external  capsule,  and 

* The  narrow  strip  of  white  matter  between  the  claustrum  and  the  island 
of  Reil  {vide  Fig.  26)  is  called  the  ‘ capsula  extrema  ’ (J.  H.  M.). 


ASSOCIATIVE  PATHS 


75 


gradually  diminishes  in  bulk  in  proportion  as  the  fibres  composing 
it  become  scattered  in  the  temporal  lobe.  Consequently,  I partly 
agree  with  Dejerine,  who  considers  this  bundle  composed  mostly  of 
short  fibres.  I would  add,  however,  that  besides  the  short  fibres, 
which  are  in  the  majority,  there  are  some  long  ones  which  establish 
more  direct  relations  between  the  frontal  and  parieto-temporal  lobes 
(Figs.  31  and  32). 

The  two  figures  here  shown  are  taken  from  two  monkeys’  brains 
treated,  one  by  Weigert’s  method,  the  other  by  Marchi’s,  and  both 
show  degeneration  of  a bundle  of  the  external  capsule  which  comes 


Fig.  31. 

FO,  Fronto-occipital  bundle;  FA,  arcuate  bundle;  FACE,  arcuate  bundle  which 
becomes  projected  into  the  external  capsule. 

from  the  arcuate  bundle.  Marchi’s  method  permits  a clear  de- 
monstration of  the  course  of  this  bundle,  belonging,  without  doubt, 
to  the  system  of  the  superior  longitudinal  bundle,  and  shows  that, 
after  passing  through  a tract  of  the  external  capsule,  it  becomes 
projected  into  the  parietal  and  temporal  lobes. 

The  Occipito- frontal  Bundle. — In  brains  that  have  undergone 
mutilation  of  the  frontal  lobes,  and  have  subsequently  been  treated 
by  either  Weigert’s  or  Marchi’s  method,  in  addition  to  a large  quan- 
tity of  fibres  running  into  the  somsesthetic  zone,  and  diminishing  in 
number  in  proportion  as  we  proceed  in  sections  from  before  back- 
wards, two  bundles  in  particular  are  found  exhibiting  degeneration 


76 


PSYCHIATRY 


in  the  serial  sections — one  to  the  outside  of  the  foot  of  the  corona 
radiata  and  the  centrum  ovale,  belonging  to  the  system  of  the 
superior  longitudinal  bundle,  is  projected  into  the  external  capsule  ; 
the  other,  much  more  internal,  runs  on  the  head  of  the  nucleus 
caudatus,  is  intersected  by  fibres  of  the  corpus  callosum,  and  can 
be  followed  for  a long  distance,  preserving  almost  always  the  same 
relations  ; this  is  the  so-called  fronto-occipital  bundle  of  Forel  and 
Onufrowicz. 

My  researches  have  shown  how  this  bundle  has  nothing  in  common 


Fig.  32. — Vertical  Section  of  a Brain  of  a Monkey  in  a Plane  correspond- 
ing TO  THE  Anterior  Rolandic  Convolution. 

Fo,  Fronto-occipital  bundle  ; Face,  portion  of  the  arcuate  bundle  in  the  external 
capsule  ; I,  insula  ; Ss,  fissure  of  Sylvius. 


with  the  arcuate  bundle.  It  is  separated  from  the  ventricular 
cavity  by  means  of  the  subependymal  gray  substance,  and  is  found, 
in  contrast  with  the  other,  at  the  internal  part  of  the  corona  radiata. 
Throughout  its  course  this  bundle  sends  no  fibres  either  to  the  corpus 
callosum — the  fibres  of  which  intersect,  almost  at  a right  angle, 
those  of  the  bundle  in  question — or  to  the  nucleus  caudatus.  Unlike 
Wernicke,  I have  not  been  able  to  follow  a true  projection  of  fibres 
of  this  bundle  into  the  internal  capsule.  Above  all,  Weigert’s 
method  shows  us  that  the  internal  capsule  contains  a few  degenerated 
fibres,  but  it  is  not  improbable  that  these  come  directly  from  the 
posterior  part  of  the  frontal  lobe,  a,nd  are  seen  when  the  section 


ASSOCIATIVE  PATHS 


77 


has  fallen  too  near  the  anterior  Rolandic  convolution  ; only  in  some 
sections  is  it  possible  to  observe  the  passage  of  a few  fibres  from  the 
fronto-occipital  bundle  to  the  internal  capsule.  At  the  level  of  the 
tail  of  the  caudate  nucleus  this  bundle  becomes  scattered,  and  more 
difficult  to  follow  by  the  method  of  consecutive  degenerations,  because 
of  the  fact  that  it  is  becoming  always  more  and  more  intersected 
by  other  systems  of  fibres.  Dejerine  speaks  of  fibres  which  detach 
themselves  from  this  bundle  to  reach  the  external  capsule.  I have 
reason  to  believe  that,  as  recently  mentioned,  the  degenerated 
fasciculus  found  in  the  external  capsule  belongs  to  the  arcuate 
bundle,  and  hence  has  nothing  to  do  with  the  occipito-frontal 
bundle.  It  is  true,  however,  that  some  degenerated  fibres  are 
found  in  the  tapetum,  but  such  fibres  are  demonstrable  by 
Weigert’s  method  only,  while  Marchi’s  does  not  disclose  them  ; 
that  is  to  say,  in  all  probability  the  degeneration  of  the  tapetum 
is  secondary  and  indirect. 

With  such  systems  of  fibres,  thedrontal  lobe  assumes  associative 
relations  with  almost  the  whole  cerebral  mantle.  In  fact,  it  is 
brought  into  relation  with  the  motor  or  somsesthetic  zone  by  a very 
large  number  of  fibres,  which  spread  themselves  out  to  form  some- 
thing like  a cone  with  the  apex  at  the  frontal  pole  ; with  the  tem- 
poro-parietal  lobe  it  establishes  direct  relations,  through  the  medium 
of  that  part  of  the  arcuate  bundle  which  passes  through  the  external 
capsule  ; with  the  occipital  lobe  a connection  is  formed  by  means  of 
the  fronto-occipital  bundle  ; with  the  limbic  lobe  by  means  of  the 
cingulum  ; with  the  anterior  part  of  the  temporal  lobe  by  means  of 
the  arcuate  bundle. 

The  Inferior  Longitudinal  Bundle. — This  bundle  extends  from  the 
occipital  to  the  temporal  pole,  while  along  its  course  it  gives  off 
a large  number  of  fibres  to  the  occipital  convolutions,  and  especially 
to  the  cuneus,  the  fusiform  and  lingual  lobules,  and,  on  the  other 
hand,  to  the  angular  gyrus,  to  the  second  parietal  convolution,  and  to 
, the  temporal  convolutions.  From  this  it  seems  clear  that  this  bundle 
is  composed  of  long  and  short  fibres,  and  establishes  associative 
relations  between  two  great  cortical  provinces — the  occipital  on  the 
one  hand  and  the  parieto-temporal  on  the  other  (Figs.  30  and  33). 

The  occipital  lobe  possesses  a system  of  associative  fibres  of  its 
own,  divisible  into  five  bundles,  which  are  : 

{a)  The  calcarine  layer,  consisting  of  vertical  fibres  forming  a 
thick  layer  of  white  substance  attached  to  the  cuneus,  and  uniting 
the  superior  to  the  inferior  lip  of  the  calcarine  fissure,  and  the  in- 
ternal aspect  of  the  cuneus  to  the  lingual  convolution.  It  is  quite 
natural  that  this  bundle  should  consist  of  fibres  of  different  lengths, 
according  to  the  distance  of  the  parts  connected,  and  it  must  extend 
from  the  occipital  pole  to  the  limbic  lobe. 

{h)  The  vertical  or  ferpendicular  occipital  bundle  of  Wernicke 
connects  the  superior  with  the  inferior  border  of  the  occipital  lobe 


78 


PSYCHIATRY 


that  is  to  say,  the  first  occipital  convolution  with  the  third  and  the 
fusiform  lobule.  It  extends  to  the  parietal  lobe,  diminishing  in 
bulk,  and  unites  the  angular  gyrus  to  the  second  and  third  temporal 
convolutions. 


Fig.  33. 

CA,  Cornu  ammonis  ; Cc,  corpus  callosum  ; Cg,  dentate  convolution  ; Cing, 
cingulum  ; CR,  corona  radiata  ; ds,  diverticulum  of  the  subiculum  ; Fc,  fasciculus- 
cinereus  ; Fli,  inferior  longitudinal  bundle;  Ft,  tangential  fibres;  Fus,  fusiform 
lobule  ; H,  convolution  of  the  hippocampus  ; ip,  iph  interparietal  sulcus  and  its 
indentations  ; L,  first  limbic  convolution  ; Lg,  lingual  lobule  ; Lms,  superficial 
medullary  lamina  ; ot,  collateral  sulcus  ; P1P.2,  first  and  second  parietal  convolu- 
tions ; Pc,  angular  gyrus  ; Plch,  choroid  plexus  ; PrC,  precuneus  ; RTh,  thalamic 
radiations  of  Gratiolet  ; see,  sinus  of  the  corpus  callosum  ; sp,  spi,  subparietal 
fissure  ; Sge,  subependymal  gray  substance  ; T2T3,  second  and  third  temporal  convo- 
lutions ; tjt.2,  first  and  second  temporal  sulci  ; tf„  indentation  of  the  second  temporal 
sulcus  ; Tap,  tapetum  ; tec,  taenia  tecta  ; VI,  lateral  ventricle.  (From  Dejerine.) 


(c)  The  transverse  occipital  bundle  of  the  cuneus  (Sachs)  is  com- 
posed of  fibres  arising  from  the  superior  lip  of  the  calcarine  fissure 
(cimens),  and  projecting  themselves  transversely  outwards,  thus 


ASSOCIATIVE  PATHS 


79 


uniting  the  cuneus  to  the  convexity  and  to  the  infero-external  border 
of  the  occipital  lobe.  According  to  Sachs,  some  fibres  of  this  bundle 
reach  the  superior  parietal  lobule  and  the  angular  gyrus. 

(d)  The  transverse  occipital  bundle  of  the  lingual  lobule  of  Vialet 
is  analogous  to  the  preceding  bundle,  but  takes  origin  from  the 
inferior  lip  of  the  calcarine  fissure  ; its  fibres  also  reach  the  external 
face  of  the  occipital  lobe. 

(e)  The  cuneate  layer  proper  (Sachs)  is  formed  of  ^fibres  running 
from  the  superior  lip  of  the  calcarine  fissure  to  the  upper  border  of 
the  hemisphere. 


Fig.  34. — Vertical  Section  corresponding  to  the  Posterior  Part  of  the 

Insula. 

b,  Destructive  focus  which  cuts  off  all  the  communications  of  the  two  temporal 
convolutions  (mn) ; the  respective  fibres  curve  round  the  temporo-insular  angle  (ti), 
pass  through  the  external  capsule  (ce),  and  reach  the  frontal  operculum,  turning 
round  the  fronto-insular  angle  (fi). 


Lastly,  I mention  here  the  temp  or  0- frontal  bundle.  This  bundle 
arises  from  the  first  temporal  convolution,  curves  round  the  temporo- 
insular  sulcus,  passes  below  the  insula  into  the  outermost  capsule, 
.and  perhaps  also  into  the  external,  reaches  the  fronto-insular  angle, 
and  becomes  projected  into  the  third  frontal  convolution.  It  is 
the  bundle  by  means  of  which  the  first  temporal  convolution  exer- 
cises its  regulative  influence  on  the  centre  of  Broca,  and  a lesion  of 
which  produces  the  so-called  paraphasia  (Fig.  34).  Through  the 
medium  of  these  better-known  bundles  of  associative  fibres,  and 
many  others  either  less  well  known  or  less  important,  numerous  and 
strict  relations  are  secured  between  distant  and  neighbouring  regions 


8o 


PSYCHIATRY 


of  the  cerebral  mantle — relations  which  are  the  essential  conditions 
of  harmonious  action  on  the  part  of  the  various  regions  of  the  cortex, 
possessing  as  they  do  such  different  functions,  and  whose  products, 
associated,  fused,  and  combined  with  one  another,  concur  in  the 
formation  and  development  of  the  personality  and  the  reaction  of 
the  latter  upon  the  environment. 

Minute  Anatomy  of  the  Cerebral  Cortex 

Cerebral  physiology  and  positive  psychology,  which  hitherto 
were  without  any  certain  and  decided  direction,  have  now  taken 
their  trend  from  the  doctrine  of  the  localization  of  the  functions  of 
the  cerebral  cortex — a doctrine  whose  soundness  is  indisputable, 
and  which  in  its  turn  embodies  the  results  of  unexpected  advances 
in  morphology.  Each  of  these  departments  of  science  has  added  its 
quota  to  our  notions  of  the  seat  of  the  elementary  as  well  as  the 
more  complex  psychic  phenomena  through  which  the  human  mind 
manifests  itself,  in  the  infinite  directions  impressed  on  it  by  time  and 
circumstances.  Not  unimportant,  too,  is  the  assistance  rendered  by 
histology,  which  promises  to  secure  for  them,  through  the  magnifi- 
cent successes  of  the  microscope,  a wider  field,  productive  of  new  and 
definite  facts,  which  may  give  to  psychological  doctrines  a sound 
foundation,  and  not  one  that  is  merely  subjective. 

The  new  methods  of  staining,  furnishing  as  they  do  fairly  precise 
notions  of  the  form  of  the  nerve  cell,  its  prolongations,  and  its  rela- 
tions with  other  cells,  both  neighbouring  and  distant,  as  well  as  the 
intimate  structure  of  the  cell  and  its  processes,  have  brought  to 
psychology  the  means  of  formulating  hypotheses  concerning  the 
function  of  the  nerve  elements,  either  as  isolated  members  or  inter- 
posed in  the  inextricable  network  permeating  the  whole  organism, 
and  forming  the  nerve  centres  in  an  especial  manner  ; and  they  have 
furnished  indisputable  proof  that  Nature,  from  the  simplest  to  the 
highest  manifestations  of  her  energies,  follows  always  the  same  plan 
and  the  same  laws,  and  that  to  that  unavoidable  law  of  the  number, 
the  complexity  of  organization,  and  the  combinations  and  associa- 
tions, among  the  others,  even  thought  is  strictly  subservient. 

As  already  mentioned,  the  cerebral  cortex  (and  of  it  alone  can  w’e 
treat  in  this  work)  is  composed  of  an  interminable  number*  of 
cerebral  units,  of  cells  and  their  corresponding  processes,  presenting 
diverse  forms  and  dispositions,  thus  permitting  it  to  be  distinguishecd 
into  layers,  each  formed  mainly  of  nerve  elements  of  a determinecd 
form.  From  the  fact,  however,  that  these  layers  are  neither  dis+- 
tinguished  with  precision  nor  constituted  exclusively  of  cells  of  tht^ 
same  form,*  much  confusion  has  resulted  concerning  the  exact  numbeir 
of  layers  composing  the  cerebral  cortex.  I shall  here  indicate  thth 

* The  results  of  the  investigations  of  Hammarberg  have  been  entirely  confirmed 
by  B,  Thomson.  . 


MINUTE  ANATOMY  OF  CEREBRAL  CORTEX 


8i 


most  important, 
layers  : 


Meynert  distinguishes  in  the  Rolandic  zone  five 


1.  A layer  of  small,  scattered  nerve  cells  (called  also  granular 

or  molecular  layer). 

2.  A layer  of  small  aggregated  pyramidal  cells. 

3.  A layer  of  large  pyramidal  cells. 

4.  A layer  of  small  pyramidal  cells. 

5.  A layer  of  fusiform  cells. 

The  above  five  layers  are  brought  to  six  by  Bewan  Lewis,  Gowers 
and  Kolhker  ; are  reduced  to  four  by  Boll,  Schwalbe,  and  Ramon 
y Cajal,  and  to  three  by  Golgi. 

The  latter  is  certainly  right  when  he  says  that  Meynert’s  distinc- 
tion of  five  layers  is  arbitrary,  a precise  demarcation  being  impossible, 
and  the  differences  between  the  various  zones  occurring  ^raduallv 
The  three  layers  of  Golgi  would  be  : 

1.  A superficial  layer,  comprising  the  upper  third  of  the  cortex 
and  formed  of  small  pyramidal  cells,  and  a somewhat  smaller  number 
of  polygonal  and  globular  cells. 

2.  A second  layer  composed  of  pyramidal  cells  of  both  large  and 
medium  size,  and  occupying  almost  the  middle  third  of  the  cortex. 

3.  A third  deep  layer  formed  of  globular,  polygonal,  atypical, 
and  especially  of  fusiform  cells. 

According  to  Caj  al,  the  outermost  or  superficial  layer  is  composed 
of  tangential  nerve  fibres,  to  which  he  attaches  a special  importance 
and  of  nerve  cells,  so  that  it  may  be  regarded  as  an  additional  layer’ 
called  by  him  plexiform.  ’ 

The  disposition  of  the  cells  of  the  above-mentioned  layers  of  the 
cortex,  their  diverse  form,  and  their  various  relations,  should  suggest 
to  our  minds  a different  physiological  value  for  each  variety.  This 
conception  has  embodied  the  spirit  of  the  most  modern  histological 
investigations,  of  which  I shall  here  make  a rapid  review.  My  obiect 
w 1 be  best  attained  by  proceeding  to  give  a synoptical  description 
01  each  layer  and  its  relations  with  the  others. 

The  Plexiform,  Molecular  Zone,  or  Layer  of  Ramon  y Cajal.— 
Ihipayer  is  composed  of  a very  large  number  of  fibres  intersecting 

^ niost  iverse  manner,  so  as  to  give  a reticulated  appearance, 
with  an  abundance  of  neuroglial  cells  and  a certain  number  of  tri- 
angular or  fusiform  nerve  cells.  It  is  surmounted  at  the  surface  by 
tangential  fibres  discovered  by  Kdlliker,  and  confirmed  by  Ober- 
steiner,  Edinger,  Todl,  Martinotti,  Cajal,  and  others  ; these  fibres 
are  of  obscure  origin,  but  very  probably  come  from  the  nerve  cells, 
o IS  same  layer.  These  cells,  as  mentioned,  have  various  forms  • 
some  are  polygonal,  in  which  case  protoplasmic  processes  are  given 
o roni  the  angles  of  the  cell  body,  some  of  these  reaching  the  layer 
of  small  pyramidal  cells.  The  nerve  process  arises  either  from  the 
cell  body  or  from  the  base  of  a protoplasmic  process,  is  directed 

6 


82 


PSYCHIATRY 


towards  the  surface,  after  a horizontal  or  oblique  course,  and  sub- 
divides several  times,  giving  rise  to  fibres  which  never  descend  into 
the  white  substance. 

Others  are  fusiform,  and  give  rise,  from  each  pole,  to  a stout  trunk, 
which  runs  for  some  distance  in  a straight  line,  then  gives  off  ascend- 
ing branches  towards  the  surface,  where  they  break  up  into  othei 
very  long  filaments  having  all  the  appearance  of  nerve  fibres  rami- 
fying in  the  territory  of  the  molecular  layer, 
and  coming  into  relation  with  the  protoplasmic 
ramifications  of  the  pyramidal  cells  of  the 
underlying  layers.  These  cells  would  have  no 
protoplasmic  processes,  but  only  nerve  pro- 
cesses. 

Others,  again,  are  triangular  or  stellate. 
These,  as  their  name  indicates,  present  three 
or  more  angles,  from  each  of  which  one 
branch  is  given  off,  to  run  in  a horizontal 
direction  for  a longer  or  shorter  distance. 
These  branches  supply  fine  collaterals  to, 
and  ramify  in,  the  molecular  zone,  trans- 
forming themselves  into  filaments  having  the 
appearance  of  axis  cylinders. 

It  is  in  this  more  or  less  dense  network  of 
ramified  nerve  processes,  coming  from  the 
special  cells  of  this  layer,  that  there  terminate 
the  ascending  ramifications  of  the  pyramidal 
cells  of  the  underlying  layers. 

According  to  Cajal,  the  special  corpuscles 
of  this  layer  may  represent  association  cells 
of  enormous  importance,  establishing  dynamic 
relations  with  the  ramifications  of  the  pyra- 
midal cells  of  the  neighbouring  convolutions. 

Layer  oj  the  Small  and  the  Large  Pyramidal 
Cells. — Some  authorities  would  regard  this  as 
consisting  of  two  layers  distinguished  only  b}^ 
the  different  sizes  of  the  cells  composing 
them,  the  more  superficial  being  smaller,  and 
becoming  gradually  larger  towards  the  deeper 
layer,  so  as  to  constitute  the  third  layer  of  these  authorities, 
which  consists  almost  exclusively  of  large  pyramidal  cells. 
These  cells,  both  small  and  large,  have  in  particular  a pyramidal 
form,  with  the  apex  above  and  continued  into  the  pyramidal  proto- 
plasmic trunk,  which  pursues  its  course  upwards,  giving  off  collaterals 
at  varying  distances  ; these,  in  their  turn,  ramify  and  end  in  a 
splendid  basket-work  or  bouquet  composed  of  terminal  protoplasmic 
arborizations,  lying  free  in  the  molecular  layer. 

Besides  the  principal  protoplasmic  trunk,  other  protoplasmic 


EDF,  Polymorphous 
cells  of  the  molecular 
layer ; H,  horizontal  or 
tangential  fibres  coming 
from  cells  of  this  zone 
at  a great  distance ; a, 
minute  ramifications  hav- 
ing all  the  appearances 
of  axis  cylinders. 


MINUTE  ANATOMY  OF  CEREBRAL  CORTEX  83 


prolongations  are  given  off  at  different  points  of  the  cell  body,  at  a 
light  or  acute  angle,  and  these  also  dichotomize  and  terminate  freely 
in  different  directions  some  horizontally,  others  obliquely  upwards 
or  downwards  (basal  protoplasmic  processes). 

From  the  bases  of  these  cells  are  given  off  the  nerve  processes 

one  only  for  each  cell — proceeding  in  a downward  direction,  travers- 
ing all  the  layers  of  the  cerebral  cortex,  and  finally  reaching  the  white 
substance.  During  its  course  it  gives  off  some  collaterals,  which,  as 
a rule,  detach  themselves  at  right  angles,  run  for  some  distance  in 
a horizontal  or  oblique  direction,  and  terminate  freely  in  two  or  three 
small  branches,  while  the  nerve  prolongation,  without  losing  its 
mduuduality  (Golgi),  becomes,  in  the  ordinary  course  of  affairs,  a 
projection  fibre,  and  proceeds  towards  its  destination.  The  prin- 


AB. 


Fig.  36. — Large  and  Medium-sized  Pyramidal  Cells. 

cell  ; 


b.  medium  Wramidal  c^^rnd^desSn^dinfarnTt  SdlSndln.; 

Uunk  ramified  in  the  zone  of  the  giant  cells  ; axon  ; d,  protoplasmiS 


cipal  collaterals  of  the  axis-cylinder  processes  of  the  small  pyramidal 
cells  most  frequently  ramify  in  the  same  cell  layer,  but  some,  accord- 
ing to  Schafer,  turn  upwards  again  in  order  to  ramify  in  the  molecular 

'yrMTi  Ck 


The  last  layer  is  composed  of  polymorphar  cells— stellate,  poly- 
gonal, fusiform— and  some  large  and  small  pyramidal  cells.  The 
majority  have  no  determined  disposition  as  regards  the  protoplasmic 
expansion  and  the  axis-cylinder  process  ; on  the  contrary,  the  great 
expansion  so  characteristic  of  the  pyramidal  cells,  is  here  'almost 
entirely  absent  and  there  is  found  instead  short,  stout,  protoplasmic 
processes  ramifying  and  sending  collaterals  and  arborizations  in 
d fferent  directions.  It  is  in  this  layer  that  we  find  cells  with  a short 
cy  inder  axis,  dividing  and  subdividing  in  the  gray  matter  itself, 
losing  their  proper  individuality  (sensory  corpuscles  of  Golgi)  • 
cewise  a large  number  of  cells  with  cylinder  axis  turning  upwards’ 

6 — 2 


84 


PSYCHIATRY 


and  giving  off  some  collaterals  along  its  ascending  course,  finally 
terminating  with  arborizations  either  in  the  molecular  layer  or,  more 
rarely,  in  the  layer  of  the  small  pyramidal  cells  (Fig.  38). 

The  researches  of  Cajal,  Hammarberg,  and  Schlapp  have  de- 
monstrated notable  differences  in  the  structure  of  different  functional 
provinces.  While  Hammarberg  distinguishes  the  motor  from  the 


Fig.  37. 


A,  Plexiform  zone  ; BC.’zone  of  the  small  and  medium  pyramidal  cells  ; a and  p, 
descending  axis-cylinder  prolongations  ; b,  recurrent  collateral  ; c,  dendrites  of  the 
giant  pyramidal  cells  ; t,  caudal  protoplasmic  trunk  ; ppl,  basal  protoplasmic  process. 


sensory  type,  Schlapp  and  Cajal  recognise  a different  structure  in 
the  cortical  areas  of  projection  and  association  (?). 

The  olfactory  area,  for  example,  is  recognised  by  the  great 
density  of  the  molecular  zone,  and  the  absence  of  small  pyramidal 
cells,  in  place  of  which  we  find  stout  triangular  cells  or  fusiform 
corpuscles  (Colleja,  Kolliker). 

The  cortex  of  the  zone  of  association  (and  also  that  of  the  motor 
and  acoustic  zones)  would  be  composed  of  six  layers  : (i)  Plexiform  ; 
(2)  small  pyramidal  cells  ; (3)  large  pyramidal  cells ; (4)  granules, . 
or  small  pyramidal  cells,  mixed  with  small  stellate  cells  ; (5)  deep, 


MINUTE  ANATOMY  OF  CEREBRAL  CORTEX 


medium,  and  large  pyramidal  cells  ; (6)  fusiform  and  polymorphous 
corpuscles.  The  disposition  of  these  layers,  and  the  number  and 
form  of  the  cells  composing  them,  vary  in  the  different  physiological 
zones  ; thus,  e.g.,  Schlapp  recognises  eight  layers  in  his  visual  type, 
and  Cajal,  in  a very  recent  work,  enumerates  the  layers  of  the 
cortex  of  the  calcarine  fissure  as  high 
as  nine. 

This  is  not  the  place  to  enter  into 
great  detail  concerning  the  structure 
of  the  different  cortical  areas,  all  the 
more  that  such  notions  have  not  yet 
received  confirmation,  as  Hitzig  oppor- 
tunely made  evident  at  the  recent 
International  Congress  at  Paris,  in 
talking  of  the  doctrine  of  Flechsig.  I 
reproduce,  after  Cajal,  however,  the 
figure  of  a section  of  the  visual  cortex 
of  an  adult  man  (Fig.  41). 

The  nerve  processes  of  all  these 
varieties  of  cells  help  to  form  the  mass 
of  white  substance  of  the  cerebral 
hemisphere,  composed  of  fibres  of 
diverse  origin  and  direction.  Of  these, 
we  distinguish  : 

1.  Projection  fibres,  which  reach 
the  optic  thalamus,  the  lenticular 
nucleus,  the  cerebral  peduncle,  and  the 
pons ; some  of  these,  without  becoming 
interrupted,  go  to  form  the  pyramidal 
bundle,  and  come  partly  from  the  large 
pyramidal  cells  (Monakow)  and  partly 
from  the  small  pyramidal  cells  (Cajal). 

2.  Association  fibres,  which  es- 
tablish communications  between  cells 
at  more  or  less  distant  points  of  the 
same  hemisphere.  They  are  supplied 
to  a great  extent  by  the  fusiform  (Figs. 

39  and  40)  and  polymorphous  cells  of 
the  lower  layer  of  the  cortex,  the 
after  detaching  collaterals,  terminate  either  in  a bifurcation  or  a 
T-shaped  division  (Fig.  40,  g).  Since  the  two  branches  of  the 
bifurcation  frequently  take  a different  or  an  opposite  direction,  it  is 
deal  how  distant  cells  and  cell  groups  can  be  brought  into  relation 
with  one  another.  In  addition,  we  must  take  into  consideration 
the  collaterals  given  off  at  various  distances  along  their  course,  some 
of  them  terminating  in  the  white  substance,  or  entering  into  relations 
with  the  protoplasmic  processes  descending  into  the  white  substance. 


BCE,  Cells  frequently  found  in 
the  fourth  layer  of  the  visual  zone, 
with  ascending  axon  a,  which  is 
distributed  either  to  the  zone  of 
the  large  pyramidal  cells  or  to  the 
zone  ofi  the  medium  cells,  or  else 
loses  its  proper  individuality  (sen- 
sory cell  of  Golgi,  E). 

nerve  processes  of  which. 


86 


PSYCHIATRY 


3.  Callosal  Fibres. — These  are  formed  either  by  nerve  processes 
of  the  cells  or  by  their  collaterals,  and  they  bring  into  relation  with 
one  another  (though  the  mode  of  termination  of  the  said  fibres  is  yet 
very  obscure)  both  symmetrical  and  asymmetrical  regions  of  the 
two  hemispheres.  Still  other  fibres  exist,  but  enough  has  been  said 
in  this  brief  review  to  give  one  an  idea  of  the  complicated  mechanism 
of  the  cerebral  functions,  based  upon  the  knowledge  which  has 
accrued  so  largely  from  the  method  of  Golgi. 

Another  field  of  inquiry  was  opened  by  the  same  eminent  histo- 
logist concerning  the  manner  of  termination  of  all  the  ramifications 
of  the  nerve  prolongations,  as  well  as  the  protoplasmic  processes. 
In  other  words,  in  what  manner  are  relations  established  between 
different  nerve  elements  and  between  these  and  the  neuroglia 
elements  ? 

Two  doctrines  contend  for  the  supremacy.  The  first,  that  of 


BS,  Cells  with  horizontal  axon  (a),  found  frequently  in  the  zone  of  the  medium 
and  small  pyramids  of  the  visual  cortex. 

Gerlach  and  Golgi,  after  a period  of  almost  complete  abandonment, 
allies  itself  with  the  more  recent  doctrine  of  Apaty,  and  moulds 
itself  upon  the  fundamental  conception  of  the  anastomosis  of  the 
processes  of  the  nerve  cells — transmission  of  the  nerve  wave  by  con- 
tinuity. The  second  doctrine,  favoured  by  Cajal,  V.  Gehuchten, 
Lenhossek,  and  many  others,  considers  the  cell,  with  its  processes,  as 
an  embryological,  anatomical,  and  functional  unit — the  so-called 
neurone  of  Waldeyer,  endowed  with  a certain  power  of  contractility 
or  amoeboidism,  its  processes  not  forming  any  anastomosis  with  those 
of  other  neurones,  but  transmitting  the  nerve  wave  in  a certain  direc- 
tion through  contiguity  or  contact.  This  doctrine  conforms  to  a 
conception  of  His,  who,  not  convinced  of  the  continuity  of  the 
nervous  reticulum,  promulgated  the  theor}^  of  the  existence  of  a 
nervous  filter  or  diffuse  nervous  substance  capable  of  transmitting 
the  nerve  current,  to  which  he  gives  the  name  of  neuropile.  The 
important  bearing  of  such  doctrines  upon  physiology  and  pS3^chology 
justifies  us  in  entering  into  fuller  details. 


DOCTRINE  OF  THE  NEURONE 


87 


According  to  Gerlach,  the  reticulum  would  be  formed  of  proto- 
plasmic processes,  while  the  axis-cylinder  processes  would  remain 
independent.  Golgi,  as  a consequence  of  the  discovery  of  his  well- 
known  method  with  the  nitrate  of  silver,  overturned  the  conception 
of  Gerlach  in  the  sense  that  the  nervous  reticulum  (the  existence  of 
which  he  confirmed,  and  has  remained  the  most  convinced  supporter) 
is  not  composed  of  protoplasmic  processes,  but  of  axis-cylinder 
processes  and  their  collaterals.  The  protoplasmic  processes, 
according  to  Golgi,  do  not  take  any  part  in  the  conduction  of  the 
nerve  current.  They  are  organs  of  nutrition  for  the  nerve  cell,  and 


Fig.  40. 

B,  Layer  of  the  stellate  and  fusiform  cells ; C,  layer  of  the  pyramidal  cells  with 
arched  axon  ; g,  triangular  cells  with  stout  collaterals— the  axis  cylinder  of  one  of 
them  divides  almost  like  a T ; e,  fusiform  element  with  descending  axon  giving  off 
many  collaterals  in  opposite  directions ; ff,  fusiform  horizontal  cells  ; hh,  pyra- 
midal cells  with  arched  or  recurrent  axon ; p,  ascending  axis-cylinder  prolongation 
of  a pyramidal  cell. 


therefore  terminate  freely,  most  frequently  in  contact  with  the 
capillary  vessels. 

We  come  now  to  the  doctrine  of  the  neurone.  The  neurone, 
according  to  the  supporters  of  this  doctrine,  is  an  anatomical  and 
physiological  unit,  and  is  composed  of  three  parts— the  cell  body, 
the  axis-cylinder  process,  almost  always  single,  and  the  protoplasmic 
processes  in  variable  number.  The  neurones  come  into  relation  or 
articulation  with  one  another  by  contact  ; every  process  or  collateral 
ends  in  arborizations  which  establish  relations  with  those  of  other 
neurones,  the  arborizations  of  the  protoplasmic  processes  of  one 
neurone  always  with  those  of  the  axis-cylinder  processes  of  another  ; 
the  wave  is  transmitted  from  the  axis-cylinder  to  the  protoplasmic 
processes.  The  cell  is  the  source  of  the  energy,  which  is  cellulifugal 


88 


PSYCHIATRY 


ilW. 


1 »f‘  ^ ■*'4>-  \ 


in  the  axis-cylinder  and  cellulipetal  in  the  protoplasmic  processes 
(laws  of  dynamic  polarization  of  V.  Gehuchten).  Thus,  for  example, 

in  the  cerebral  cortex  the  dendritic  ex- 
pansion of  the  pyramidal  cells  receives 
the  nerve  waves  from  the  arborizations 
of  the  ascending  axis-cylinder  process 
of  the  sensory  cells,  and  transmits  them 
to  the  body  of  the  pyramidal  cell,  which 
in  its  turn  transmits  them,  through  its 
axis  cylinder,  to  the  protoplasmic 
arborizations  of  the  cells  of  the  anterior 
cornua  of  the  spinal  cord ; thus,  the 
neurones  are  distinguished  into  sensory 
and  motor.  The  one  set  receives  the 
impulses  from  without,  and  transforms 
them  into  nervous  or  psychic  waves, 
and  then  transmits  them  to  the  motor 
neurones,  determining  reflexes  from  the 
simplest  to  the  most  complex.  On  the 
other  hand,  amoeboidism,  applied  to 
the  nervous  system  of  the  higher 
animals,  or,  more  exactly,  to  the  axis- 
cylinder  and  protoplasmic  processes 
(the  expansion  and  retraction  of  which 
serve  to  establish  and  break  the  con- 
tacts between  the  various  neurones), 
taken  along  with  the  existence  of 
associative  cells  which,  by  means  of 
axis-cylinder  and  dendritic  processes 
of  great  length,  exchange  their  products 
with  distant  neurones,  was  capable  of 
giving  us  the  key  to  the  comprehension 
of  a number  of  cerebral  phenomena — 
e.g.,  the  reawakening  of  diverse  images 
when  only  one  group  of  neurones  is  put 
in  vibration,  all  the  phenomena  of  the 
association  of  ideas,  of  memory,  of  ab- 
stract thought,  of  actions,  and  so  on, 
which  led  Brissaud  to  observe,  ‘ Should 
we  be  dealing  with  an  insuflicient 
innervation,  or  an  excessive  innervation, 
the  amoeboid  neurone  gives  the  key 
to  all.’ 

According  to  this  doctrine,  the 
active  part  of  the  neurone  is  the  cell 
the  axis-cylinder  process  has  no  other 
of  the  nerve  current.  The  vibration 


Fig.  41. — Cortex  of  the  Cal- 
carine Fissure  of  an  Adult 
Brain. 

I,  Plexiform  zone;  2,  zone 
of  the  small  pyramidal  cells  ; 

3,  zone  of  the  medium  pyra- 
midal cells  ; 4,  zone  of  the 
large  stellate  cells ; 5,  zone  of 
the  small  stellate  cells;  6, 
zone  of  the  small  pyramids 
with  ascending  axon  ; 7,  zone 
of  the  giant  pyramidal  cells  ; 

8,  zone  of  the  pyramidal  cells 
with  ascending  arched  axon  ; 

9,  fusiform  cells. 

with  its  dendrites,  while 
task  than  the  conduction 


DOCTRINE  OF  CONTINUITY  89 

commences  in  the  dendrites,  is  directed  to  the  cell  body,  and  thence 
passes  to  the  nerve  fibre.  The  dendrites  would  play  a very  im- 
portant part  in  the  nutrition  of  the  cell,  because  they  also  lie  bathed 
in  the  same  lymphatic  fluid  as  the  cell  body,  which,  on  the  other 
hand,  exercises  a trophic  influence  on  the  axis-cylinder  process ; 
the  latter,  consequently,  degenerates  if  separated  from  the  cell  body. 

Viewed  in  the  light  of  this  doctrine,  the  importance  of  the 
dendrite  is  carried  to  the  highest  degree,  because  its  substance, 
alive  and  motile,  would  react  with  amoeboid  movements  under  the 
influence  of  external  stimuli.  It  would  likewise  have  a tendency  to 
produce  new  buds  and  new  protoplasmic  ramifications  under  new 
conditions  of  existence.  In  like  manner,  under  the  influence  of 
stimuli,  the  gemmulae  of  the  dendrite  would  increase  in  number, 
and  the  functional  and  nutritive  surface  of  the  cell  would  accordingly 
be  augmented. 

While,  however,  the  doctrine  of  the  neurone  was  finding  sym- 
pathy in  the  more  important  scientific  centres,  and  psychologists  and 
neuropathologists  were  taking  it  up,  as  offering  a probable  anatomical 
basis  to  the  interpretation  of  psychic  phenomena,  Apaty,  Paladino, 
Bethe,  and  Held  entered  into  the  field  to  check  its  victorious  march, 
and  to  extinguish  the  enthusiasm  of  its  fervid  supporters,  by  ad- 
ducing the  result  of  new  investigations,  and  restoring  life,  under 
another  form,  to  the  almost  vanquished  doctrine  of  the  nervous 
reticulum  of  Golgi. 

Paladino,  using  his  method  of  staining  by  the  iodide  of  palladium, 
has  observed  relations  of  continuity — true  anastomosis — between  the 
nerve  processes  of  neighbouring  and  distant  cells.  These  results 
were  confirmed  by  the  researches  of  Fragnito  and  Capobianco.  Of 
great  importance  are  the  observations  of  Apaty  and  Bethe,  who, 
save  for  unimportant  differences  in  their  results,  would  appear  to 
have  demonstrated  that  the  nervous  system  is  composed  of  a con- 
tinuous, inextricable  network  of  nerve  fibrillse,  extracellular  and 
intracellular,  without  any  interruption.  The  nerve  cell,  with  its 
protoplasmic  processes,  is  interposed  in  the  course  of  the  nerve  fibres, 
like  the  electric  piles  in  the  course  of  an  electric  network.  The  axis- 
cylinder  processes  are  composed  of  neuro-fibrillae  (Apaty),  and  these, 
in  their  turn,  of  primitive  fibrillae,  constituting  a continuous  reti- 
culum, either  intercellular,  pericellular,  or  intracellular.  There  is 
thus  no  interruption  between  sensory  fibres  and  motor  fibres.  In 
the  epithelial  cells  of  the  organs  of  sense  a fine  nervous  reticulum  is 
found,  formed  of  primitive  fibrillae,  which  collect  the  waves  from 
external  stimuli.  These  primitive  fibrillae  would  constitute,  outside 
the  epithelial  cells,  the  neuro-fibrillae,  which,  in  their  turn,  would 
form  the  axis  cylinder  of  a ganglionic  nerve  cell.  Within  the  cell 
body  the  axis  cylinder  resolves  itself  into  the  neuro-fibrillae,  and  these 
form  the  endocellular  reticulum,  and  issue  from  the  cell  body  again 
in  the  form  of  an  axis  cylinder.  If  amongst  the  neuro-fibrillae  there 


90 


PSYCHIATRY 


is  one  stouter  than  the  others,  this  is  a motor  fibre,  and  so  would  only 
represent  the  continuation  of  the  sensory  neuro-fibrillae. 

A still  more  important  fact,  however,  is  that  the  neuro-fibrillae 
forming  an  axis  cylinder  do  not  always  penetrate  into  the  cell,  but 
some,  after  arriving  at  the  ganglion,  resolve  themselves  into  primi- 
tive or  elementary  fibrillae,  and  form  a thick  pericellular  and  inter- 
cellular network.  The  nerve  cells  would  only  be  bodies  interposed 
along  the  course  of  the  nerve  fibrils,  like  the  heart  in  the  vascular 
system,  which  forms  one  continuous  whole.  The  fact  that  the  nerve 
fibrils  and  their  networks  can  exist  outside  the  cell  would  greatly 
magnify  their  value  as  compared  with  the  diminished  importance  of 
the  cell. 

Bethe  agrees  with  Apaty  on  the  independence  of  the  neuro- 
fibrillae  as  regards  the  nerve  cell.  According  to  him  also,  the  cell 
is  only  interposed  in  the  course  of  the  nerve  fibres.  These,  whether 
sensory  or  motor,  converge  towards  a central  point  situated  in  the 
middle  of  the  nerve  ganglion.  This  point  to  which  the  fibrils  con- 
verge is  called  by  him  neuropile  (a  kind  of  carrefour,  as  the  French 
would  say),  and  is  extracellular,  so  much  so  that  whilst  the  peripheral 
nerve  cells  of  the  ganglion  may  be  destroyed,  yet  the  motor  reflex  is 
preserved.  The  motor  fibre  can  arise  from  the  intercellular  network 
outside  the  cell.  Bethe  is  much  more  reserved,  however,  on  the 
question  of  the  anastomotic  reticulum  of  the  nerve  processes  and 
the  contiguity  of  their  terminations. 

The  independence  of  the  nerve  fibre  as  regards  the  cell  (without 
mentioning  the  protoplasmic  processes,  which,  according  to  the 
doctrine  of  Apaty  and  Bethe,  lose  the  character  and  value  assigned 
to  them  by  the  doctrine  of  the  neurone)  is  also  supported  by  an 
embryological  fact  of  great  importance — namely,  the  formation  of 
the  axis  cylinder  independently  of  that  of  the  nerve  cell.  Here  we 
have  to  deal  with  autochthonous  formations  by  metamorphosis  of 
special  embryological  cells,  giving  rise  to  the  axis  cylinder.  Another 
blow  is  also  given  to  the  doctrine  of  the  neurone  by  the  researches  of 
Fragnito,  assistant  at  my  clinique,  who  discovered  this  other  fact, 
that  the  nerve  cell  itself  is  not  an  embryological  unit,  but  results  from 
the  fusion,  by  a particular  process,  of  several  neuroblasts.  These 
results,  highly  important  as  they  are,  have  recently  been  confirmed 
also,  save  for  unimportant  differences,  by  Capobianco.  Hence,  the 
doctrine  of  Golgi,  under  another  guise,  becomes  again  victorious. 
Golgi’s  method  does  not  succeed  in  revealing  the  intimate  structure 
of  the  cell  in  all  its  particulars.  This  is  shovm  more  clearly,  however, 
by  the  methods  of  staining  called  after  Nissl,  who  introduced  them. 
After  Nissl,  Lenhossek,  Held,  Flemming,  Heinke,  Paladino,  Cajal, 
Van  Gehuchten,  Marinesco,  Lugaro,  Colucci,  Levi,  and  others,  have 
contributed  to  give  us  a somewhat  precise  and  uniform  description 
of  the  nerve  cell,  both  in  the  normal  state  and  under  the  influence  of 
various  pathogenic  agents. 


MINUTE  STRUCTURE  OF  NERVE  CELL 


91 


The  protoplasm  of  the  nerve  cells  is  composed  of  two  parts — the 
chromophilic,  or  colourable  portion,  and  the  achromatic  part. 
The  achromatic  part  of  the  cell  protoplasm  consists,  in  its  turn,  of 
two  fundamental  substances,  one  organized — the  protoplasmic 
network  (Van  Gehuchten) — and  one  unorganized,  filling  up  the 
meshes  of  the  network.  The  trabeculae  and  nodal  points  of  the 
meshes,  and  more  particularly  those  at  the  periphery  of  the  nerve 
element,  are  encrusted  with  a substance  (disposed  as  bodies  of 
diverse  form  and  size)  which  takes  on  the  stain  of  the  basic  aniline 
dyes,  and  forms  the  so-called  chromatic  or  stainable  portion  of  the 
nerve  cell.  These  are  the  so-called  Nissl  bodies. 

The  unstainable  portion  possesses  the  greater  biological  impor- 
tance, especially  if  we  take  into  account  the  fact  that  the  fibriUse 
forming  the  nerve  prolongation  and  the  protoplasmic  processes 
take  origin  from  it.  Held,  Heinke,  Flemming,  Cajal,  Marinesco, 
Lugaro,  and  others  have  shown  that  in  the  cell  of  the  spinal  ganglion 
the  single  nerve  process  arises  from  a part  of  the  nerve  element, 
usually  central,  where  chromatophilic  bodies  are  not  always  found, 
called  by  Flemming  the  polar  cone,  and  having,  according  to  the 
majority  of  observers,  a distinctly  fibrillar  structure.  The  fibres  of 
the  cone  are  prolonged  into  the  fibres  of  the  axon,  and  would  appear 
to  take  origin  from  the  trabeculae  of  the  reticulated  substance.  The 
axis-cylinder  process,  then,  is  composed  of  fibrils  (neuro-fibrill^  of 
Apaty)  arising  from  those  forming  the  endocellular  reticulum. 

What  has  been  observed  in  the  case  of  the  cells  of  the  spinal 
ganglia  holds  good  also  for  the  motor  cell,  though  here  the  matter  is 
more  difficult  of  demonstration.  No  great  stress  need  be  laid  on  the 
difficulty  raised,  that  the  nerve  process  sometimes  arises  from  a 
protoplasmic  process  ; on  the  contrary,  this  argument  may  be  turned 
the  other  way  when  it  is  considered  that  the  fibrillar  structure  of  the 
dendrites,  as  well  as  of  the  axon,  can  itself  explain  the  apparent 
anomaly,  on  the  ground  that  the  course  of  the  fibres  composing  each 
is  different. 

The  fibrils  in  the  cytoplasm  sometimes  assume  a concentric  dis- 
position around  the  nucleus  or  in  parts  removed  from  it,  and  while 
in  some  instances  there  is  no  exchange  of  anastomosis,  in  other  cases, 
and  in  some  animals  in  particular,  an  exchange  of  anastomosis 
between  the  fibrillae  may  be  observed. 

The  colourable  portion  is  represented,  in  addition  to  the  in- 
crustations on  the  trabeculae,  by  little  blocks  having  a definite  or 
irregular  contour,  an  elongated,  ellipsoid,  oval,  or  irregular  form,  and 
sometimes  a granular  aspect,  according  to  different  elements  and  in 
different  animals.  These  little  blocks  often  converge  in  the  prin- 
cipal dendrite  (protoplasmic  process),  becoming  thinner  and  more 
elongated  the  farther  from  the  cell  body  (Fig.  44)  ; they  are  found 
both  large  and  small,  and  in  some  animals  are  exceedingly  small — 
almost  granular,  in  fact. 


92 


PSYCHIATRY 


In  some  instances,  however,  they  are  found  in  greater  concentra- 
tion around  the  nucleus. 

The  nucleus  consists  of  a membrane,  a reticulum  (protoplasmic 
reticulum)  which  is  stained  with  Biondi’s  fluid,  of  acidophil  particles 
(basic  chromatin,  or  nuclei  of  Lenhossek),  and  of  one  and  sometimes 
more  nucleoli  (two  or  three),  consisting  of  a central  acidophil  part 
and  two  to  three  basophil  particles,  which  take  on  a deep  azure  with 
methyl  green  and  are  disposed  near  the  periphery. 

In  the  dendrites  the  chromophilic  particles  become,  as  already 
mentioned,  longer,  thinner,  and  rarer ; they  appear  to  be  bound  to 
one  another  by  short  undulating  fibres,  but  in  proportion  as  the 
particles  disappear  the  fibrils  appear  straighter,  thinner,  and  more 
parallel  to  the  axis  of  the  dendrite.  These  fibrils  are  continuous 
with  those  of  the  peripheral  part  of  the  cell. 

The  chromophilic  particles  do  not  exist  in  the  period  of  embryonic 
formation  of  the  nerve  cell.  Before  the  third  month  the  most  that 


Fig.  42.  Scheme  of  the  Nervous  Reticulum,  continuous  from  S — Sensory 
Surface — to  M,  Muscle. 

is  found  is  a certain  quantity  of  chromophilic  substance  dissolved 
in  the  cell  body.  It  is  only  from  the  third  month  onwards,  according 
to  Biewliet,  from  the  fourth,  according  to  Dell’  Isola,  that  it  is  found 
in  the  form  of  solid  particles  and  granules.  At  first  these  are  found 
only  at  the  periphery  of  the  nerve  cell  ; later,  with  the  increase  of  the 
cell  protoplasm,  the  particles  advance  towards  the  centre,  and  draw 
nearer  to  the  nucleus.  Fragnito  offers  as  an  explanation  of  this  fact 
the  doctrine  that  the  increase  of  the  cell  is  due  to  the  neuroblasts 
disposed  at  its  periphery  augmenting  the  cell  protoplasm.  According 
to  this  theory,  the  appearance  of  the  chromophilic  particles  coincides 
with  the  transformation  of  the  embryonal  cells,  the  chromatic 
reticula  of  these  condensing  to  form  the  chromatic  particles  of  the 
adult  cell ; and  it  is  natural  that  the  first  layer — the  external — 
should  become  more  internal  in  proportion  as  the  new  elements  are 
superimposed  on  the  periphery  of  the  cell  and  transformed  into  its 
protoplasm. 

The  chromophilic  substance  is  less  stable  than  the  fibrillar 
substance.  It  seems  certain,  from  the  investigations  of  Hodge, 


MINUTE  STRUCTURE  OF  NERVE  CELL 


93 


Mann,  Demoor,  and  Pergens,  that  activity  of  the  nerve  cell  is  accom- 
panied by  augmentation  of  the  volume  of  its  protoplasm  and  diminu- 


Fig.  43. — Scheme  of  the  Tract  and  the  Connections  of  the  Neuro-Fibrils 
IN  THE  Leech.  (After  Apaty.) 

fs,  Sensory  fibrillae  ; fm,  motor  fibrillae  ; c.  gg.  s,  sensory  cells  ; c.  gg.  m,  motor 
cells  ; r.  n.  ext.,  diffuse  nervous  reticulum  of  Apaty  ; r.  n.  int.,  intracellular  nervous 
reticulum  ; c.  gg,  ganglionic  cell. 

tion  of  its  chromophilic  substance.  This  fact  agrees  with  another 
previously  observed  by  Nissl,  that  nerve  cells  belonging  to  the  same 
morphological  type  present  great  differences  in  the  amount  of  their 


94 


PSYCHIATRY 


chromophilic  substance.  The  same  author  proposes  the  terms  picno- 
morphic,  apicnomorphic,  and  parapicnomorphic  states  for  the  three 
degrees  of  colorability  of  the  cells,  these  corresponding  to  so  many 
momentary  functional  states.  Following  the  same  line  of  investiga- 
tion as  Nissl,  and  pursuing  the  same  method  upwards  instead  of 
downwards,  others,  such  as  Lambert,  Mann,  Lugaro,  and  Hodge, 
have  confirmed  the  fact  that  more  or  less  intense  and  prolonged 
excitation  of  a nerve,  or  of  the  ganglion  itself,  induces  modifications 
in  the  anatomical  state  of  the  respective  nerve  cells.  The  general 
conclusion  drawn  by  the  above-mentioned  authorities,  however, 
is  severely  criticised  by  Van  Gehuchten,  who  disputes  the  theory  that 


Fig.  44. — Nerve  Cele  prepared  by  Nissl’s  Method  (which  does  not  disclose 
THE  Nuclear  Reticulum). 

PP,  Protoplasmic  prolongations  ; PA,  axis-cylinder  prolongation  ; N,  nucleus  ; 
NO,  nucleolus  ; CN,  Nissl  bodies. 


artificial  excitation  of  a cell  by  means  of  the  faradic  current  can 
identify  itself  with  the  state  of  physiological  activity  of  the  same. 
That  there  is  a strong  probability  in  the  conception  of  Nissl  must, 
however,  be  acknowledged,  as  it  is  very  likely  that  the  chromophilic 
substance  is  a reserve  material  intended  for  the  nutrition  of  the  nerve 
cell. 

Meanwhile  a large  number  of  observations  have  set  beyond  all 
doubt  the  fact  that  both  in  states  of  fatigue  consequent  upon  ex- 
cessive cell  action  (Stefanovska)  and  by  the  action  of  pathogenic 
agents — infections,  autointoxications,  poisonings,  powerful  electric 
shocks  (Corrado),  such  as  those  of  lightning — a change  in  the  cell 
structure  is  induced,  which  in  the  first  stage  consists  of  a diminution 
or  disappearance  of  the  Nissl  bodies  (chromatolysis,  or,  better. 


STRUCTURE  OF  NEUROGLIA 


95 


cytolysis),  and  in  the  second  stage  in  the  disappearance  also  of  the 
reticulum  of  endocellular  fibrilla:  (cytoclasis,  V.  Gieson).  This  is 
extremely  important  from  the  fact  that  cytolysis  is  reparable  in  a 
longer  or  shorter  time,  because  the  Nissl  bodies  regenerate,  while 
cytoclasis  is  not  recoverable,  or,  in  other  words,  is  not  followed  by 
what  ^ an  Gieson  calls  cytothesis.  We  shall  see  further  into  this 
matter,  however,  when  dealing  with  the  pathological  anatomy  of 
the  mental  affections.  ^ 


In  recent  times  we  have  had  affirmation  of  the  existence  of  fine 
canaliculi  in  the  nerve  cell,  irripting  its  protoplasm,  and,  according 
to  the  observations  of  Colucci,  communicating  with  a perinuclear 
space.  Holmgreen,  on  the  other  hand,  would  have  it  that  such 
canaliculi  communicate  with  the  extracellular  lymphatic  channels. 
It  IS  probable,  though  not  certain,  that  the  internal  reticular 
apparatus  of  the  cell  described  by  Golgi  coincides  with  the 
canaliculi  described  by  Holmgreen  and  Bethe.  We  have  still 
much  to  learn  concerning  the  relations  of  the  nerve  cells 
with  the  lymphatics,  a question  which  I believe  is  entangled 
with  that  of  the  special  lymphatic  channels  indicated  in  the  brain 
by  D’Abundo. 

Neuroglia.  The  elements  composing  the  neuroglia  are  the 
ependymal  cells  and  the  arachnoid  cells,  the  processes  of  the  latter 
constitutmg  the  neuroglia  fibrils.  The  glia  cells  are  provided  with  a 
body,  w'hich  is  all  the  more  distinct  the  younger  the  animal  and  the 
further  we  descend,  in  the  scale  of  the  vertebrates. 

The  ependymal  cells  line  the  cavity  of  the  Mrebro-spinal  axis, 
and  originate  from  the  epithelial  cells,  which,  conjointly  with  the 
germinal  cells,  constitute  the  whole  thickness  of  the  wall  of  the 
primitive  neural  canal.  The  arachnoid  cells  are  found  in  the  gray 
as  well  as  in  the  white  substance  of  the  nerve  centres.  Both  kinds  are 
provided  with  processes. 

The  glia  cells  are  elements  in  the  course  of  evolution,  and  when 

n u*  nucleus  disappears  or  falls  away,  and  then  the 

cell  body  seems  like  a point  of  intersection  of  fibrils. 

The  evolution  of  the  glia  cells  would  explain  the  presence  of  so 
many  nuclei  in  the  neuroglia,  besides  allowing  us  partly  to  understand 
the  finding  of  Ranvier,  Weigert,  and  others,  who  dispute  the  indi- 
viduality of  the  complete  neuroglia  cell,  and  maintain  that  the  fibres 
are  independent  of  the  cells. 


The  processes  belonging  to  the  neuroglia  cells  differ  in  length  and 
are  variously  ramified  ; one  in  particular  is  much  thicker  than  the 
others.  Some  maintain  that  the  neuroglia  processes  cross  one 
another  without  anastomosis,  but  it  is  much  more  probable  that 

processes  of  neighbouring  cells,  and 
other^  with  those  of  more  distant  cells.  Thus  we  have  a disposition 
1 proximal  and  distant  relations,  a fact  which,  while  opposed  to 
opinions  previously  advanced,  yet  in  part  affords  an  explanation 


96 


. PSYCHIATRY 


of  them.  For  the  most  part,  the  stouter  process  serves  for  the 
proximal  relation  between  two  glia  cells. 

From  the  extensive  application  of  the  chrome-silver  method,  we 
may  reasonably  admit  the  termination  of  the  processes  or  neuroglia 
fibrils  on  the  adventitia  of  the  bloodvessels.  After  treatment,  in 
the  first  instance,  by  the  iodide  of  palladium  (Paladino),  and  then  by 
differential  staining,  it  is  possible  to  demonstrate  that  the  neuroglia 
processes  are  continuous  also  with  the  pia  mater,  and  take  up 
absolutely  new  relations  with  the  cells  and  the  nerve  fibres — that 
is  to  say,  (a)  the  neuroglia  becomes  less  plentiful  around  the  nerve 
cells,  forming  a pericellular  reticulum  (neuroglia  network),  with 
narrow  meshes  and  small  corpuscles  inserted  on  its  nodal  points. 
It  is  very  probable  that  this  superficial  network  may  be  continued 
into  the  interior  of  the  cell  body  (Paladino) ; {h)  the  neuroglia  pene- 
trates the  myelin  sheath  of  the  nerve  fibres,  and  constitutes  their 
skeleton  (myelinic  neuroglia  of  the  medulla  of  the  nerve  fibres).  The 
nodes  of  Ranvier  and  notches  of  Lantermann,  etc.,  would  be  part  of 
this  skeleton. 

These  relations  are  particularly  evident  in  some  vertebrates,  but 
are  quite  distinct  in  all,  including  man  and  mammals,  in  both  normal 
and  pathological  conditions. 

These  new  relations  between  the  neuroglia  and  the  nerve  elements, 
confirmed  by  Coined  as  regards  the  retina,  and  in  the  nerve  centres 
of  the  vertebrate  series  by  Capobianco  and  Fragnito,  constitute  a 
discovery  of  the  highest  importance  in  the  architecture  of  the 
cerebro-spinal  axis.  According  to  Prinke,  again,  two  orders  of 
neuroglia  elements  would  exist — first,  those  put  in  evidence  by  the 
chrome-silver  method  (the  spider  cells,  with  their  proper  protoplasmic 
processes,  terminating  freely  or  otherwise) ; and,  second,  neuroglia 
fibres  independent  of  the  cells,  and  morphologically  and  chemically 
different  from  the  cell  bodies  : these  would  be  formed  certainly 
from  the  protoplasm  of  the  neuroglia  cells,  from  which,  however, 
they  would  be  set  free  in  the  course  of  development. 

As  regards  the  function  of  the  neuroglia,  they  are  now  few  who 
maintain  that  it  must  serve  merely  as  a supporting  tissue.  Golgi 
holds  that  the  processes  of  the  neuroglia  cells  come  into  relation 
with  the  processes  of  the  nerve  cell,  and  serve  for  the  nutrition  of  the 
latter. 

Others  affirm,  somewhat  hypothetically,  that  the  neuroglia 
processes  are  interposed  between  the  nerve  fibres  in  order  to  isolate 
them,  and  thus  impede  functional  contacts  (Cajal,  Sala).  The  fact 
that  the  neuroglia  cells  are  found  in  great  number  around  the  vessels 
and  enveloping  the  nerve  centres  has  given  some  the  idea  (Andriezen) 
that  one  of  the  functions  of  the  neuroglia  cells  is  that  of  protecting 
the  nerve  cells  against  sudden  dilatation  of  the  vessels,  and  also 
against  vibrations  due  to  shocks  from  without  (Weigert). 

According  to  Cajal,  the  nerve  cell  arborizations  are  not  endowed 


STRUCTURE  OF  NEUROGLIA  97 

with  amoeboid  movements  for  the  establishment  or  interruption  of 
contacts.  On  the  contrary,  it  would  be  the  contraction  or  expansion 
of  the  neuroglia  elements  that  would  permit  or  impede  the  contacts 
between  the  nerve  elements  ; acting  like  pseudopodia,  they  would 
constrict  or  dilate  the  capillaries,  and  finally  serve  as  regulators  of 
the  circulation  in  the  gray  matter,  in  both  phases  of  repose  and 
activity. 

The  same  authority  regards  the  form  and  mechanism  of  the 
neuroglia  cells  of  the  gray  substance  as  characteristic.  Sometimes 
their  processes  are  short  and  thick,  sometimes  long  and  besprinkled 
with  secondary  and  tertiary  offshoots.  According  to  this  histologist, 
the  cells  with  short  processes  would  represent  a state  of  activity,  during 
vhich  they  remain  free  from  contacts  with  the  nerve  processes. 
Those  with  long  and  branching  processes  would  be  in  a state  of 
relaxation  ; they  would  be  interposed  between  the  protoplasmic 
processes  and  the  axis  cylinders  of  the  nerve  cells,  and  would  impede 
their  contacts.  This  conjecture  lacks  any  basis  of  proof  whatsoever 
and  has  a merely  historical  value. 

On  the  other  hand,  Marinesco  would  contend  that  the  neuroglia 
has  a tendency  to  encroach  upon  the  anatomical  field  of  the  nerve 
cell.  This  power  would  be  neutralized  by  a substance  secreted  by  the 
young  nerve  cell,  and  having  the  property  of  impeding  the  invasion 
and  phagocytic  tendency  of  the  nuclei  of  the  neuroglia.  Histo- 
chemical  alterations  of  the  nerve  cell  would  deprive  it  of  the  power  of 
guarding  Itself  against  the  invading  property  of  the  neuroglia,  and  in 
this  we  would  find  an  explanation  of  the  increase  of  nuclei  in  senile 
decay  and  other  pathological  states. 

Orr  and  Cowen  dispute  this  hypothesis,  refusing  to  admit  the 
phagocytic  action  either  of  the  nuclei  of  the  neuroglia  or  of  the 

observations,  they  are  able  to  assert 
hat  these  elements  are  found  in  a plane  different  from  that  of  the 
nerve  cells.  They  add,  what  we  have  held  for  a long  time,  that  the 
prolileration  of  the  neuroglia  is  secondary  to  the  degeneration  of 
the  nerve  fibres,  as  the  result  of  the  irritation  produced  by  the  to.xins 
arising  from  the  degeneration  of  the  nerve  elements  themselves. 


7 


CHAPTER  II 


PHYSIOLOGY  OF  THE  CEREBRAL  MANTLE  | 

We  have  studied  in  the  preceding  chapter  the  cortical  stations  of  | 
the  centripetal  paths  for  common  sensation  and  the  different  special 
senses,  and  those  of  the  centrifugal  paths  belonging  to  the  motor 
apparatus.  I believe,  however,  it  is  not  only  advantageous,  but 
necessary  to  some  extent,  to  turn  our  attention  upon  the  signification 
which  the  cortical  sensory  centre  and  the  motor  centre  ought  to 
have  for  us.  With  this  end  in  view,  we  can  take,  for  example,  sight, 
as  being  that  mechanism  which  has  been  best  studied  and  of  which 
the  analysis  is  most  easily  accomplished. 

Sight,  as  we  have  already  mentioned,  is  present  in  some  primordial  ■ 
representatives  of  animal  life,  such  as  the  rhizopod,  whose  eye  is  ^ 
but  a spot  composed  of  epithelial  cells  which  fix  the  luminous  rays  ; i 
it  is  found  in  insects  which  do  not  yet  possess  a cerebral  mantle,  ’ 
but  specialized  cell  aggregations  (optic  ganglia)  ; also  in  fish,  in  t 
some  of  which,  as  stated  in  the  introduction,  there  exists  certainly  J 
a cerebral  mantle,  but  in  a rudimentary  condition.  In  the  higher 
mammals  and  in  man,  besides  the  optic  ganglia,  represented  by  the 
corpora  quadrigemina,  we  have  the  optic  thalami  and  other  centres 
differentiated  in  the  cerebral  mantle  now  enormously  developed.  : 
Such  successive  formation  of  new  organs  destined  for  the  same  j 
function  must  lead  us  to  associate  the  gradual  development  of  that  1 
function  with  the  appearance  of  numerous  new  anatomical  com-  | 
ponents,  the  introduction  of  which  may  add  a further  contribution  | 
towards  the  attainment  of  the  object  ultimately  to  be  reached. 

One  can  have  a simple  luminous  impression  with  no  other  know- 
ledge of  the  illuminated  object  save  in  so  far — and  this  only  con- 
fusedly— as  regards  its  relation  to  space.  Of  a certainty  one  cannot 
deny  to  this  phenomenon  the  character  of  sensation — incomplete  and 
rudimentary,  it  is  true,  because  there  are  wanting  the  various  qualities 
and  attributes  through  the  medium  of  which  one  can  form  an  idea 
of  the  object  in  question,  and  bring  into  play  the  judgments  fof 
analogy,  similarity,  dissimilarity,  etc.,  which  tell  us,  not  only  the 
optic  quality  of  the  object,  but  also  its  special  relations,  such  as  its 
form,  size,  and  position  with  respect  to  others.  These  latter  attri- 

98  I 


PHYSIOLOGY  OF  THE  VISUAL  CENTRES 


99 


butes  must  be  furnished  us  by  anatomical  components  different  from, 
but  naturally  associated  with,  those  destined  to  receive  the  luminous 
impression,  which  must  be  quite  as  distinct  in  the  anatomical  aspect 
as  in  the  physiological.  Indeed,  we  judge  of  the  size  and  form  of  an 
object  by  the  fact  that  its  image  on  the  macula  lutea  becomes  dis- 
placed through  the  movements  of  the  ocular  bulb.  Such  movements, 
as  a general  rule,  give  rise  to  images  of  muscular  sense  (of  movements 
completed)  which  are  closely  associated  with  those  produced  by  the 
zone  of  projection  of  the  retina  upon  the  cortex  ; and  both  are  neces- 
sary that  we  may  have  the  precise  image  of  the  object  which,  in  my 
opinion,  results  from  the  physiological  fusion  of  distinct  products, 
furnished  by  two  elementary  components — the  retino-cortical  and 
the  kingesthetic.  The  latter  (the  components  of  the  visual  image 
which  refer  to  the  form  and  volume  of  the  object)  is  furnished  by  the 
centripetal  currents  which  proceed  from  the  external  muscles  con- 
cerned in  the  movements  of  the  bulb  in  every  direction,  and  from 
the  muscles  of  accommodation. 

Hitzig,  Ferrier,  Luciani  and  Tamburini,  Bianchi,  Bechterew, 
Munk,  and  as  many  others,  found  in  the  dog,  as  well  as  in  the  monkey, 
cortical  areas  (the  second  external  convolution  of  the  dog,  the  angular 
gyrus,  and  the  anterior  part  of  the  occipital  operculum  of  the  monkey), 
excitation  of  which  produces  movements  of  conjugate  deviation 
of  the  eyes  in  various  meridians.  Schafer,  experimenting  even  more 
methodically  than  the  observers  just  mentioned,  defined  the  cortical 
motor  points  of  the  eyes  a little  differently  from  Bechterew,  with  the 
result  that  we  now  know  that  special  zones  govern  special  move- 
ments in  a determined  meridian.  Excitation  of  the  superior  zone 
of  the  occipital  lobe  produces  downward  movements  of  the  eyes  ; 
that  of  the  inferior  part  produces,  on  the  other  hand,  upward  move- 
ments. Stimulation  of  the  intermediate  zone  gives  rise  to  lateral 
movements  of  the  ocular  bulbs.  The  movements  are  more  intense 
when  the  interhemispheric  aspect  of  the  occipital  lobe  is  excited. 

It  serves  no  useful  purpose  to  discuss  here  by  what  means  the 
movements  of  the  ocular  bulbs  are  accomplished.  The  hypothesis 
of  Ferrier,  received  favourably  by  Munk,  Steiner,  and  Schafer— that 
such  movements  may  be  necessary  to  arouse  the  visual  images  pro- 
jected upon  a given  quarter  of  the  visual  field  by  the  excitation  of 
determined  areas  of  the  cortical  visual  zone — cannot  be  retained  as 
proven.  Without  question,  we  must  admit  the  existence  of  centri- 
fugal fibres  from  the  visual  zone  to  the  subcortical  centres  of  the 
ocular  movements  (corpora  quadrigemina).  Munk,  Steiner,  and 
others  hold  this  view. 

This  interpretation  is  not  exempt  from  impartial  criticism.  The 
supposition  that  the  ocular  movements  provoked  by  electric  excita- 
tion may  be  manifestly  the  consequence  of  vision  (Schafer  and  Munk) 
is,  after  all,  a supposition  far  from  probable,  and  is  contradicted  by  a 
fact  of  great  importance — that  the  ocular  movements  of  the  infant 

7—2 


100 


PSYCHIATRY 


much  precede  the  development  of  the  cortical  visual  function  (forma- 
tion of  images),  which  is  held  to  be  developed  about  the  fifth  month. 
Confining  myself  to  a more  ample  consideration  of  the  nature  of  the 
cortical  motor  centres,  I have,  hypothesis  for  hypothesis,  no  reason 
to  change  that  which  since  1880  (‘On  the  Signification  of  Electrical 
Excitation  of  the  Cortical  Motor  Zone  ’*)  I have  formulated  concerning 
the  real  motor  nature  of  the  cortical  centres,  and  I hold  with  Panillo 
and  with  Knies  that  the  motor  conductors  of  the  occipital  lobe  con- 
cerned in  the  visual  function  enter  into  activity  without  being  them- 
selves necessarily  excited  by  the  visual  images  ; in  other  words, 
that  they  are  motor  within  the  strict  meaning  of  the  word. 

Further,  in  the  frontal  lobe  there  exist  motor  centres  for  the  ex- 
ternal and  internal  ocular  muscles.  One  is  found  in  the  immediate 
vicinity  of  the  centre  for  the  muscles  of  the  neck  (conjugate  move- 
ments of  head  and  eyes).  A little  below  and  in  front,  at  the  middle 
of  the  prefrontal  sulcus,  a point  is  found,  excitation  of  which 
always  produces  dilatation  of  the  pupils.  In  the  immediate  vicinity 
of  this  small  area  is  another,  even  more  limited,  excitation  of  which 
produces  constantly  slight  elevation  of  the  upper  eyelid  and  dilata- 
tion of  the  pupil.  Such  areas  I have  always  been  able  to  define  with 
precision  in  the  frontal  lobes  of  the  monkey.  Their  relations  are 
mostly  crossed.  The  experiments  of  Bechterew  have  confirmed 
these  by  no  means  recent  observations  of  mine.  No  one  will  think  . 
of  admitting  the  existence,  in  that  part  of  the  cerebral  mantle,  of  a : 
centre  for  visual  images  which  could  be  re-aroused  by  electric  excita-  ; 
tion,  and  that  these  would  be  able  to  produce  ocular  movements,  i 
On  the  contrary,  everything  leads  to  the  belief  that  the  frontal  ^ 
oculo-motor  area  may  be  developed  by  the  positions  assumed  by  the  t 
head  and  eyes  in  relation  to  attention.  Hence,  we  may  be  induced  to  ■ 
consider  the  points  of  excitation  mentioned  above  as  cortical  oculo-  : 
motor  areas,  and  so  become  convinced  of  the  specialization  of  work, 
and  of  the  association  of  its  products.  Anatomy  and  experiment,  ’ 
the  one  following  closely  on  the  heels  of  the  other,  have  by  proof  ^ 
arrived  at  a common  ground,  and  have  to  a great  extent  solved  the  ] 
problem  of  the  specific  function  of  the  diverse  areas  of  the  cerebral  ^ 
mantle.  I 

Meanwhile,  let  us  make  a rapid  review  of  the  experimental  facts 
which  have  been  brought  to  light,  especially  by  the  researches  of 
Hitzig,  Munk,  Monakow,  Fiirstner,  Stenger,  Loeb,  Yeo,  Luciani  and  ^ 
Tamburini,  Seppilli,  Lannegrace,  Schafer,  Beevor,  Horsley,  and 
myself. 

In  1874  Hitzig  affirmed  that  a lesion  limited  to  the  occipital  lobe 
produces  blindness  of  the  opposite  eye.  This  discovery  has  been  of 
great  consequence  in  both  physiology  and  pathology,  and  has  had 
an  important  bearing  also  on  psychology.  It  has  established  a i 


* ‘ Sul  significato  della  cccitazione  elettrica  della  zona  motrice  corticale.’ 


PHYSIOLOGY  OF  THE  VISUAL  CENTRES 


lOI 


scientific  fact  which  neither  the  researches  nor  the  quibblings  of 
Goltz  and  his  learned  pupils  have  been  able  to  discredit.  It  was 
already  known,  from  the  experiments  made  by  Panizza  and  then  by 
Gudden — even  before  the  researches  of  Hitzig  and  the  later  ones  of 
Munk  and  of  Luciani — that  some  anatomical  connections  existed 
between  the  optic  nerve  and  the  occipital  lobe.  As  regards  the 
motor  and  visual  areas,  Hitzig  and  Ferrier  were  among  the  first  to 
attempt  to  define  their  cortical  whereabouts.  Still,  the  experimenters 
mentioned  are  by  no  means  in  agreement  as  to  the  limits  to  be 
assigned  to  the  visual  area.  Ferrier  localized  the  centre  of  vision 
in  the  dog  in  the  superior  part  of  the  second  external  convolution, 
and  in  the  monkey  in  the  angular  gyrus.  Munk  is  strongly  of  opinion 
that  the  centre  for  sight  in  the  monkey  is  in  the  occipital  lobe,  with 
an  extension  to  the  parietal  lobe.  Goltz  scarcely  admits  any  func- 
tional difference  between  the  posterior  and  anterior  part  of  the  cere- 
bral hemisphere.  Luciani  and  Tamburini  contend  that  the  area  in 
question  extends  forwards  beyond  the  limits  assigned  by  Munk — a 
fact  which  was  afterwards  fully  confirmed  in  dogs  by  my  experi- 
ments. 

In  the  case  of  the  dog  the  centre  of  vision  is  not  confined  exclu- 
sively to  either  the  second  external  convolution  (especially  the  middle 
and  posterior  part)  or  to  the  occipital  lobe,  but  is  situated  both  in 
t*he  occipital  lobe  and  the  whole  of  the  external  convolution.  In 
this  matter  I find  myself  in  agreement  with  Goltz,  who,  from  the 
outset,  has  stoutly  maintained  that  the  visual  zone  in  the  cerebral 
cortex  of  the  dog  (as  he  understood  it)  is  much  more  extensive  than 
has  been  held  by  other  experimenters.  The  brain  of  the  dog  lends 
itself  badly  to  the  dispute  concerning  the  limits  of  the  cortical  visual 
zone,  because  electric  excitation  does  not  furnish  the  means  of  solving 
such  a question,  and  mutilation  does  not  give  less  uncertain  results. 
\\  hen  we  consider  for  a moment  that  even  the  destruction  of  the 
frontal  lobe — so  little  developed  in  the  dog — produces  almost  the 
same  visual  disturbances  as  are  produced  after  destruction  of  an 
occipital  lobe,  and  that  these  last  for  many  days,  we  see  how  difficult 
a matter  it  is  to  define  the  limits  of  the  visual  zone  in  the  dog,  because 
the  differentiation  of  the  individual  areas  is  much  less  advanced  than 
in  the  case  of  more  highly-developed  brains. 

We  know  positively,  however,  that  visual  disturbances  are  ob- 
served on  destroying  the  second  external  convolution  even  well  in 
front  that  is,  that  part  which  is  immediately  below  the  sigmoid 
gyrus.  The  visual  disturbances  which  result  from  the  mutilation 
of  this  part  of  the  cortex  are  often  very  grave,  and  persist  for  a long 
time,  just  as  when  a part  of  the  occipital  lobe  is  removed.  Further, 
lesions  of  the  third  external  convolution,  besides  those  of  the  frontal 
lobe,  produce  marked  visual  disturbances. 

In  the  monkey,  on  the  contrary,  the  visual  area  is  more  readily 
defined.  Munk  places  it  in  the  occipital  lobe,  but  from  the  experi- 


102 


PSYCHIATRY 


merits  of  Ferrier,  in  association  with  those  of  Yeo,  of  Luciani,  and  of 
Schafer,  it  seemed  demonstrated  that  the  cortical  visual  centre,  in 
the  monkey,  might  be  not  only  in  the  occipital  lobe,  but  also  in  the 
angular  gyrus.  It  was  my  belief  that  this  ought  to  have  held  good 
in  man  also,  because  a series  of  observations  upon  some  visual  dis- 
turbances, with  which  we  shall  concern  ourselves  later  on,  showed 
that  the  inferior  'parietal  lobe,  especially  that  part  of  it  which  goes 
under  the  name  of  angular  gyrus,  might  have  been  considered  as  the 
cortical  visual  centre  with  as  much  right  as  the  occipital  lobe  ; but 
now,  as  far  as  this  question  has  regard  to  man  and  the  monkey,  much 
doubt  has  been  thrown  upon  the  value  of  the  visual  function  of 
the  cortex  of  the  external  aspects  of  the  occipital  and  inferior 
parietal  lobes,  the  question  being  whether  the  visual  disturbances 
observed  ought  to  be  attributed  to  the  lesion  of  the  cortex  or  to 
lesion  of  the  underlying  optic  radiations. 

The  latter  theory  was  supported  with  a notable  abundance  of 
clinical  and  microscopic  evidence  by  Henschen,  to  whom  belongs  the 
credit  of  the  demonstration  that  all  the  visual  disturbances  produced 
by  lesions  of  the  external  aspects  of  the  occipital  and  inferior 
parietal  lobes  depend  upon  injury  to  the  underlying  optic  radiations 
of  Gratiolet,  because  the  visual  zone,  according  to  Henschen,  would 
include  only  that  part  of  the  internal  aspect  of  the  occipital  lobe 
which  forms  the  lips  of  the  calcarine  fissure  {vide  Chapter  I.).  If,  ■ 
however,  the  observations  of  Henschen,  confirmed  in  other  ways  by  ; 
Monakow  and  by  Dejerine,  have  to  all  appearance  settled  the  : 
question  of  the  organic  visual  disturbances  (hemiopia),  there  remain  ! 
to  be  discussed  the  other  questions — in  the  first  place,  whether  , 
the  external  aspects  of  the  occipital  and  the  inferior  parietal  « 
lobes  are  to  be  considered  as  belonging  to  the  visual  zone,  and  ' 
fulfilling  higher  visual  functions,  such  as  the  formation  and  pre-  . 
servation  of  concrete  visual  images  ; or,  secondly,  whether  indeed  ' 
they  fulfil  functions  other  than  visual.  The  first  question  is  bound  ' 
up  with  another : Is  the  visual  sensory  area  only  that  indicated  by  | 
Henschen,  or  that  more  extensive  one  of  Brissaud  and  Dejerine;  | 
or,  on  the  other  hand,  does  it  indeed  extend  as  far  as  the  parietal  \ 
lobe  ? Again,  in  this  latter  case,  is  the  function  of  the  given  zone  | 
equally  distributed  in  such  a manner  that  one  part  has  the  same 
functional  value  as  it  is  wished  to  assign  to  the  whole  extension  of  it, 
or  is  it  to  be  marked  off  into  distinct  areas  whose  sum  total  gives 
rise  to  the  perfect  product  of  the  evolved  visual  function,  which 
concerns  itself  in  the  formation  and  preservation  of  the  complete 
visual  images  ? 

Few  physiological  problems  present  such  difficulty  as  this  for  a 
solution.  Goltz,  having  regard  to  the  signification  of  the  cortical 
visual  zone,  says  that  this  area  fulfils  the  functions  of  the  so-called 
mental  vision,  which  consists  in  the  faculty  of  comprehending  the  ; 
nature  and  signification  of  the  images  which  external  objects  reflect 


PHYSIOLOGY  OF  THE  VISUAL  CENTRES 


103 


upon  the  retina.  The  destruction  of  any  part  whatsoever  of  the 
visual  area,  which,  according  to  Goltz,  is  very  extensive,  ought  to 
produce  such  visual  disturbances  that  the  animal  (by  a restriction 
of  the  sense  of  colour  and  the  sense  of  space)  sees  everything  quite 
confusedly.  But  the  doctrine  of  Goltz  is  met  by  obstacles  not  easily 
overcome,  and,  from  a certain  point  of  view,  represents  a return  to 
the  doctrine  of  Flourent.  No  advantage  will  be  gained  by  revert- 
ing to  it. 

As  already  mentioned,  attempts  have  been  made  to  demonstrate 
by  experiment  a certain  differentiation  in  the  visual  area,  because, 
when  the  polar  part  of  the  occipital  lobe  is  excited  with  electricity, 
the  result  is  negative  ; if,  however,  any  points  on  the  external  face 
of  the  occipital  lobe  are  excited,  and  especially  the  superior  part  of 
the  second  external  convolution  in  the  dog,  or  the  external  face  of  the 
occipital  lobe  and  the  angular  gyrus  in  the  monkey,  movements 
of  the  ocular  bulb  are  produced  in  the  direction  of  different  meridians. 
On  stimulating,  however,  the  anterior  tract  of  the  second  external 
convolution,  the  movements  which  result  are  no  longer  those  of  the 
ocular  bulb,  but  those  of  the  eyelids,  which  become  spasmodically 
closed,  just  as  when  we  shut  the  eyes  voluntarily  or  are  confronted 
by  a powerful  light,  the  orbicular  contraction  produced  in  this  case 
representing  reflex  action. 

The  behaviour,  so  different,  under  electric  excitation,  of  different 
parts  of  such  an  extensive  cortical  area,  partial  mutilations  of  which 
induce  more  or  less  marked  permanent  or  temporary  disturbances  of 
vision,  goes  to  signify,  in  my  opinion,  that  the  functional  attribute 
differs  in  the  individual  areas  into  which  we  may  consider  the  visual 
zone  divided.  I hold  to-day  also — and  with  more  reason  after  the 
lapse  of  many  years  since  first  I formulated  such  a hypothesis — 
that  one  of  these  areas  may  be  specially  designed  for  the  formation 
of  luminous  images,  another  for  those  of  colour,  a third  for  the  forma- 
tion of  motor  images  of  the  ocular  muscles,  and  that,  finally,  another 
part  of  that  extensive  zone  may  be  the  field  wherein  the  luminous 
images  and  those  of  the  ocular  muscles  are  fused  and  synthetized,  this 
union  resulting  in  the  visual  images  of  the  objects. 

The  different  behaviour  towards  electric  excitation  of  the  diverse 
points  of  the  cortex  of  the  visual  area  has,  on  the  other  hand, 
suggested  to  some  other  experimenters,  among  whom  are  Munk  and 
Schafer,  an  interpretation  over  which  I think  it  useful  to  pause. 
According  to  these  physiologists,  the  retina  would  be,  as  it  were, 
projected  upon  the  corresponding  cortical  visual  area  ; and  as  we 
can  imagine  each  retina  divided  into  sections,  so  also  can  we  imagine 
the  cortical  visual  area  divided  into  so  many  other  sections,  corre- 
sponding to  the  diverse  directions  impressed  on  the  ocular  bulb 
by  the  action  of  the  electric  stimulus  applied  to  the  cerebral  cortex. 
SchMer,  besides  admitting  that  the  visual  area  of  a hemisphere  may 
be  connected  with  the  two  lateral  homonymous  halves  of  both  retinae. 


104 


PSYCHIATRY 


holds  that  the  superior  zone  of  the  visual  area  of  a hemisphere  may 
be  connected  with  the  inferior  portion,  the  inferior  zone  with  the 
superior  portion,  and  the  middle  zone  with  the  middle  portion,  of 
the  corresponding  lateral  halves  of  both  retinse.  Henschen  and 
Vialet  are  inclined  to  admit  a cortical  retinal  projection,  albeit 
without  adducing  decisive  proof.  Henschen  holds  that  the  central 
and  peripheral  parts  of  the  cortical  retina,  corresponding  to  the 
homonymous  portions  of  the  ocular  retina,  would  be  situated  in  the 
anterior  and  posterior  parts  of  the  cortex  of  the  calcarine  fissure. 
With  this  view,  however,  Sachs  and  Soury  do  not  agree.  Hun  has 
made  reference  to  a case  in  which  atrophy  of  the  superior  lip  of  the 
calcarine  fissure  produced  hemianopsia  of  the  inferior  quarter  of  the 
visual  field  on  both  sides.  Another  convinced  supporter  of  these 
doctrines  is  Wilbrand,  who  also  refers  to  a case  in  which  a lesion  of 
the  inferior  lip  of  the  calcarine  fissure  gave  rise  to  hemianopsia  of  the 
superior  visual  field. 

This  division  of  the  visual  area  is  only  hypothetic,  because  ex- 
perimental destruction  of  very  limited  portions  of  the  internal  face 
of  the  occipital  lobe,  in  the  dog  and  monkey,  discloses  only  one  de- 
finite fact,  and  that  is  the  ever-recurring  phenomena  of  bilateral 
homonymous  hemianopsia  ; that  is,  given  a point  of  fixation,  accord- 
ing to  Foerster,  which  corresponds  to  the^macula  lutea,  and  given  a 
lesion  of  the  occipital  lobe  in  any  point  whatever  of  the  retinal  pro- 
jection of  one  side,  we  find  there  occurs  in  consequence  blindness  of 
the  homologous  halves  of  the  retinae,  but  its  limit  does  not  pass 
through  the  point  of  fixation. 

In  our  opinion,  the  differentiation  of  the  visual  zone  on  the  cere- 
bral cortex  into  areas  corresponding  to  the  different  sections  of  the 
retina  is  a subtle  explanation,  pleasing  to  the  preconception  of  the 
experimenter,  but  not  a fact  experimentally  and  clinically  demon- 
strated. The  constant  or  almost  constant  fact,  on  the  contrary,  is 
the  representation  on  each  cortical  visual  area  of  the  two  bundles  of 
the  optic  nerve — the  direct  and  the  crossed.  Moreover,  according  to 
Wfilbrand  and  Henschen,  each  half  of  the  two  maculae  luteae  is  in 
connection  with  the  two  cerebral  hemispheres.  Monakow  is  of  a 
like  opinion. 

Munk  advances  another  theory  : he  supposes  that  each  cortical 
visual  globe  contains  both  perceptive  elements  and  elements  which 
serve  for  the  preservation  of  images  commemorative  of  the  percep- 
tions, and  for  their  ideal  representation.  The  perceptive  elements 
correspond  to  the  cortical  retinal  elements,  and  would  be  contained 
in  the  cortical  territory  for  the  projection  of  luminous  impressions, 
the  excitations  of  which  would  be  propagated  to  the  cortical  ele- 
ments for  commemorative  representation  of  perception,  and  thence 
to  those  of  ideation.  Wdien  the  area  of  mnemonic  representations 
is  destroyed,  there  is  no  longer  possible  the  awakening  of  an  image, 
under  the  influence  of  an  excitation,  peripheral  or  central,  with  re- 


PHYSIOLOGY  OF  THE  VISUAL  CENTRES 


105 


spect  to  the  homonymous  halves  of  the  two  retinae.  An  animal  in 
this  condition  sees,  but  does  not  recognise  what  it  sees.  It  is  psychic- 
ally blind  (pyschic  blindness).  Henschen,  Wilbrand,  and  Vialet 
share  the  same  view  ; Henschen,  in  particular,  wrote  that  the 
calcarine  surface  probably  receives  the  visual  impressions  in  the  same 
manner  as  the  retina,  and  transmits  them  for  preservation  to  another 
point,  more  or  less  distant,  of  the  occipital  or  the  parietal  lobe. 
Vialet  distinguishes  a visual  centre  of  perception  and  a visual  centre 
of  memories,  connected  with  one  another  by  means  of  associative 
bundles. 

This  doctrine  of  Munk  is  contradicted  by  the  experimental  fact 
that  the  phenomena  of  blindness,  observed  in  the  greater  number  of 
the  animals  (dogs),  are  the  more  intense  and  persistent  the  more 
extensive  the  lesion  of  the  occipital  lobe.  The  mutilated  dogs  never 
become  absolutely  blind,  even  if  the  visual  zone  has  been  destroyed 
on  both  sides.  In  dogs,  as  well  as  monkeys,  the  phenomena  associ- 
ated with  hemiopia  are  noted  also  following  on  lesions  of  the  frontal 
lobes,  and  are  sometimes  persistent  for  weeks.  One  might  vary 
the  site  of  the  zone  of  psychic  blindness  in  the  sense  of  Munk,  then, 
without  any  difference  of  result  other  than  in  the  intensity  and 
duration  of  the  phenomena. 

The  accurate  researches  of  Monakow,  like  those  of  Colucci  and 
my  own,  compel  us  to  assign  a larger  area  (as  contrasted  with 
Henschen’s  ideas)  to  the  territory  of  cerebral  vision,  and  we  must 
at  least  admit  with  him  that  the  limits  of  the  visual  sphere  are  not 
definitely  fixed.  For  that  part,  psychic  blindness  can  be  produced 
by  a lesion  of  the  white  substance,  as  well  as  by  cortical  lesions. 
This  is  shown  by  the  effects  which  result  from  lesions  of  the  associa- 
tive paths  between  the  different  cortical  areas,  whose  products 
ought  to  combine  for  the  formation  of  the  idea  and  notion  of  the 
object. 

The  subject  affected  by  psychic  blindness,  in  the  sense  of  Munk, 
sees  objects,  but  does  not  recognise  them.  He  sees  like  an  indi- 
vidual who  has  never  seen  objects  in  this  world  (if  such  abstrac- 
tion were  possible),  and  knows  nothing  whatever  of  the  signification 
of  form,  weight,  or  size.  Since,  then,  the  part  surrounding  the 
destroyed  visual  zone  is  composed  of  homologous  cell  elements,  which 
can  by  education  and  evolution  perfect  themselves,  assume  relations 
with  the  intact  portion  of  the  visual  zone,  and  fix  the  images,  the 
animal  learns  by  degrees  to  recognise  objects.  This  is  the  explana- 
tion of  the  recoveries  which  ensue  within  a certain  time  of  the  occur- 
rence of  the  lesion. 

I cannot  desist  at  this  point  from  entering  into  detail  with  regard 
to  so  important  a question  of  psychology  and  anatomy.  When  it  is 
affirmed  that  the  images  are  formed  in  one  zone  of  the  cerebral 
mantle,  and  are  preserved  for  their  mnemonic  representation  in 
another  zone,  there  is  apparent  the  need  of  coming  to  an  agreement 


io6 


PSYCHIATRY 


upon  our  interpretation  of  perception,  because  the  perception  of 
one  of  the  components  of  the  concrete  image  is  one  thing,  the  per- 
ception of  the  concrete  image  as  produced  by  synthetic  fusion  of  all 
the  component  elements  whence  it  results  is  another.  Luminous 
images,  and  those  of  colour,  which  are  formed  in  the  zone  of  retinal 
projection,  represent  only  one  of  the  components  of  the  images  of 
objects  in  the  external  world.  If  this  is  true,  one  can  agree  with  the 
hypothesis  that  such  elementary  luminous  images  may  become  trans- 
mitted, by  means  of  associative  paths,  from  their  own  neurones 
to  other  neurones,  where,  blending  with  other  elementary  compo- 
nents, they  form  the  concrete  image.  But  if  by  the  zone  of  retinal 
projection  it  is  wished  to  imply  the  zone  of  perception— that  is  to 
say,  of  formation  of  the  images  of  the  objects— the  hypothesis  of 
those  who  maintain  that  there  does  not  exist  a coincidence  of  the 
centres  of  perception  and  of  representation  would  be  quite  arbitrary. 
The  point  of  commemorative  representation  of  the  images  can  only 
be  the  same  as  that  in  which  the  images  are  formed. 

Our  idea,  conformable  to  the  results  of  the  best  anatomical, 
experimental,  and  clinical  studies,  is,  as  already  stated,  that  the  visual 
area  is  rather  more  complicated  than  would  appear  from  the  earliest 
experiments.  One  part  of  it  can  be  considered  as  the  projection  of 
the  retina  upon  the  cortex,  with  due  consideration  of  the  decussation 
in  the  chiasma,  of  a part  of  the  fibres  of  the  optic  nerve.  It  is  also 
certain  that  another  part  is  a centre  for  ocular  movements,  and  so 
for  the  oculo-motor  images  ; and  it  seems  clear  that  a third  part  is 
destined  for  the  formation  and  registration  of  the  concrete  images 
which  result  from  the  physiological  fusion  of  the  two  preceding 
elementary  images.  We  must  accept  the  idea  that  the  concrete 
images  may  become  transmitted  from  the  point  of  formation  to 
other  more  or  less  distant  groups  of  neurones,  which  form  in  man 
an  evolutive  zone  destined  for  the  formation  and  preservation  of 
images  more  complex,  inasmuch  as  they  result  from  the  physiological 
fusion  of  the  concrete  visual  images  of  objects  with  others  of  a 
different  nature,  for  the  formation,  as  we  shall  see  further  on,  of  the 
verbal  images  and  the  conceptions. 

The  following  scheme  (Fig.  45),  guided  by  anatomico-physio- 
logical  knowledge,  seems  to  me  to  indicate  more  vividly  the  mode 
of  formation  of  the  visual  images,  their  components,  and  their 
relations  with  other  zones  of  the  cortex.  It  has  been  adopted 
by  me  since  1897  (vide  ‘ Sensory  Phrenosis  ’ and  ‘ Progressive 
Paralysis  ’),  and  I think  it  renders  sufficiently  clear,  not  only  the 
mechanism  of  perception,  but  likewise  those  of  judgment  and 
reaction.  The  scheme  refers  to  the  paths  and  stations  of  the  nervo- 
luminous  waves  following  an  optic  perception,  and  takes  for  granted 
the  doctrine  of  the  neurone,  which  does  not  compromise  anything. 

NR  represents  the  neurone,  which  receives  and  modifies  the 
luminous  wave  (retinal  neurone).  It  represents  diagrammatically 


PHYSIOLOGY  OF  THE  VISUAL  CENTRES 


107 


the  different  neurones  of  the  retina.  From  the  first  station,  the 
luminous  wave,  having  now  become  a nerve  wave,  is  transmitted 
along  the  fibres  of  the  optic  tract  to  the  second  neurone  TO,  repre- 
senting the  optic  thalamus,  where  it  undergoes  another  modification. 

Naturally,  the  scheme  supposes  that  the  external  geniculate  body 
acts  as  a part  of  the  optic  thalamus,  it  being  impossible  in  the  scheme 
to  introduce  the  results  of  more  recent  experiments,  from  which  it 
would  appear  proved  that  isolated  destruction  of  the  pulvinar, 
without  injury  to  the  region  of  Gratiolet  and  of  the  external  genicu- 
late body,  does  not  produce  either  hemianopsia  or  other  visual 


Fig.  45. — Scheme  indicating  the  Course  of  the  Sensory  Waves  for  the 
Formation  of  the  Concrete  Visual  Images,  the  Higher  Mental  Pro- 
ducts, AND  THE  Reflexes  of  Various  Grades. 


troubles,  though  the  pulvinar  should  be  retained  as  the  centre  of 
particular  reflexes  of  sight,  acting  upon  the  physiognomy  through 
the  emotions,  as  those  which  determine  laughing  and  weeping. 

Meanwhile,  the  nerve  wave  NR — TO,  independently  of  its  con- 
nections with  the  optic  thalamus,  can  also,  by  means  of  a collateral 
of  the  nerve  prolongation  of  NR,  meet  the  motor  neurone  OM  by 
the  path  NR — OM  : that  is  to  say,  the  nucleus  of  the  oculo-motor 
nerve,  thus  determining  the  simplest  reflex.  The  nerve  wave  from 
the  neurone  TO  passes,  by  means  of  the  optic  radiations  or  thalamo- 
cortical fibres,  to  the  neurone  RC,  representing  the  visual  cortical 
zone,  or,  rather,  that  part  of  it  known  as  the  retinal  projection  of 


io8 


PSYCHIATRY 


the  cortex  (lips  of  the  calcarine  fissure,  cuneus,  occipital  pole). 
The  nerve  wave  next  produces  in  RC  the  phenomenon  of  psychic 
light,  but  cannot  yet  be  the  image  of  the  object  whence  came  the 
first  luminous  vibrations.  This  very  complex  result  is  obtained  by 
the  intervention  of  the  senso-motor  element,  over  which  presides 
another  anatomical  apparatus.  Contemporaneously  with  the  wave 
NR — TO — RC,  by  means  of  the  collateral  TO — OM,  or  even  the 
other  NR — OM,  the  nerve  wave,  which,  let  us  suppose,  has  produced 
in  TO  a simple  sensation  without  distinct  knowledge  of  the  object 
(as  certainly  occurs  in  the  lower  animals,  although  in  man  the  optic 
thalamus  has  various  functions,  as  just  mentioned),  is  itself  trans- 
mitted to  OM  and  to  M (external  and  internal  ocular  muscles). 
Given  the  psychic  fact  of  the  sensation,  this  reflex,  which  comes  by 
means  of  the  path  TO — OM,  is  much  more  complex  than  the  first, 
NR — OM.  By  it  the  eye  is  directed  upon  the  luminous  object,  by 
reason  of  adapted  movements.  These,  meanwhile,  determine  centri- 
petal waves  of  muscular  sense,  which  either  directly  join  the  cortex 
CCS  or  indirectly — that  is  to  say,  after  interruption  in  a subcortical 
station — before  reaching  the  cortical  senso-motor  centre  of  the  eye. 

As  is  known  from  recent  histological  researches,  the  fibres  of  common 
sensation  are  furnished  with  ganglia  which  are  found  on  their  course, 
and  in  the  scheme  are  represented  by  the  cell  CS.  The  centripetal 
neurone  CS  transmits  to  the  other  neurone  CCS  the  sensory  nerve  ■ 
wave  produced  by  the  contraction  of  M.  In  the  neurone  CCS  we  ; 
have  formed  and  registered  the  senso-motor  image  of  the  internal  i 
and  external  ocular  muscles.  From  the  neurone  CCS  the  nerve  wave  ! 
in  part  discharges  itself  upon  the  cortical  motor  centre,  rightly  , 
speaking,  of  the  ocular  muscles  CCM,  from  which  the  nerve  wave  | 
reaches  OM,  and  in  part  is  transmitted  to  the  neurone  IV,  for  the 
purpose  of  receiving  and  resolving  the  psycho-luminous  wave  trans- 
mitted by  RC,  the  sensory-muscular  wave  transmitted  by  CCS,  and  • 
the  motor  wave  transmitted  by  a collateral  of  CCM.  All  these  ’ 
factors  constitute  the  visual  image  of  the  object  which  is  the  result  | 
of  their  physiological  fusion.  The  visual  image,  on  the  one  hand,  I 
becomes  transmitted  as  a nerve  wave  to  F (frontal  lobe),  where,  by  < 
physiological  fusion  with  a greater  or  less  number  of  other  visual  | 
images  and  those  of  other  senses,  it  takes  part  in  the  formation  of  the 
products  of  a superior  order  (associated  groups — abstract  concep- 
tions), and,  on  the  other  hand,  comes  into  relation  with  the  neurone 
ZM,  which  represents  in  the  scheme  the  cortical  motor  zone.  This, 
in  its  turn,  is  also  in  relation  with  the  neurone  F (and  it  could  also  be 
so  with  the  neurone  RC).  Such  connections  show  clearly  how  some 
actions  or  movements  can  be  determined  by  nerve  waves  from  RC 
directly  to  ZM,  others  by  nerve  waves  from  IV  to  ZM,  and  others, 
again,  by  the  nerve  waves  F — ZM. 

We  see  as  a result  how*  this  scheme  permits  of  the  interpretation  < 
of  many  of  the  more  important  psychic  phenomena,  and  what  signifi- 


PHYSIOLOGY  OF  THE  MOTOR  AREA 


109 


cation  is  to  be  accorded  to  the  transmission  of  the  content  of  IV  to  F. 
The  other  sensory  areas  we  already  know  from  what  has  been  said  of 
them  in  connection  with  the  chapter  on  anatomy,  and  it  will  be  more 
useful  to  return  to  them  in  the  second  part  of  this  work,  when  dealing 
with  perception  and  its  disturbances. 

Let  us  now  see  what  signification  should  be  attributed  to  the  motor 
zone,  but  first  of  all  let  us  make  a brief  historical  review. 

In  1870  Fritsch  and  Hitzig,  experimenting  on  the  cerebral  cortex 
of  the  dog,  defined  some  small  areas  exactly  in  the  sigmoid  gyrus, 
excitation  of  which,  by  electricity,  produced  movements  limited  to 
certain  groups  of  muscles  which  altered  according  to  the  area  excited. 
In  this  way  there  came  to  be  defined  the  areas  which  govern  the 
shoulder,  the  paw,  and  all  the  superior  limb,  besides  those  for  the 
movements  of  flexion,  extension,  etc.,  of  the  posterior  limb. 

Hitzig,  continuing  his  experiments  on  the  monkey,  elicited  the 
same  facts,  and,  in  addition,  found  the  areas  still  better  defined  and 
differentiated,  the  monkey’s  brain  being  more  developed  than  that 
of  the  dog  ; and,  pursuing  still  further  his  researches — which  have 
remained,  and  will  remain,  the  solid  foundation  of  all  future  progress 
— he  divided  the  cerebral  cortex  of  the  dog  and  the  monkey  into 
functional  areas,  on  a secure  basis,  and  was  able  to  prove  that  these 
same  muscles  which  contracted  under  the  action  of  electricity 
remained,  at  least  temporarily,  paralyzed  when  their  respective 
centres  were  destroyed. 

Almost  contemporaneously  (a  few  weeks  later)  Ferrier,  in 
England,  demonstrated  the  same  facts  ; as  a result,  control  experi- 
ments were  made  on  every  side,  so  that  there  now  stands  confirmed 
this  fundamental  fact  : that  it  is  far  from  true  that  the  cortex  of  the 
brain  fulfils  functions  equal  and  universal  in  all  its  parts  ; that,  on 
the  contrary,  it  is  distinguished  into  different  areas  of  diverse  func- 
tional dignity,  some  related  to  organs  of  sense,  one  in  particular 
being  responsive  to  electric  excitation,  and  destruction  of  which  is 
followed  by  paralysis  of  movement  in  the  limbs  of  the  opposite  side. 

Goltz,  Schiff,  Brown-Sequard,  and  a few  other  physiologists  were 
the  only  ones  who  cast  a doubt  on  the  whole  matter.  It  would  appear 
that  the  existence  of  a motor  centre  is  capable  of  easy  demonstration 
by  the  fact  alone  that,  on  destroying  the  sigmoid  gyrus  of  the  cere- 
bral cortex  of  the  dog,  or  the  Rolandic  zone  of  the  monkey,  the 
animal  remains  paralyzed  in  the  limbs  of  the  opposite  side  ; the  dog, 
for  example,  walks  with  its  paw  bent  upon  the  dorsum,  or  drags  it 
along,  or  performs  irregular  movements  similar  to  those  seen  in  the 
subjects  of  ataxia,  or  shows,  at  least,  loss  of  power  on  that  side. 
Much  discussion  has  been  raised,  however,  concerning  the  nature  of 
such  disturbances,  and  hence  of  the  function  of  that  part  of  the  brain, 
inasmuch  as  Goltz,  with  many  others,  has  maintained  that  it  really 
contains  no  cortical  motor  centres.  Schiff,  among  the  others, 
thought  to  prove  that  the  paralysis  in  the  dog  and  in  the  monkey 


no 


PSYCHIATRY 


might  be  apparent  only,  and  dependent  upon  anaesthesia  of  the 
limbs  ; that  is  to  say,  the  destruction  of  the  corresponding  area 
resulted  in  the  abolition  of  sensibility  in  the  opposite  side,  but  of 
nothing  else. 

Aroused  by  the  experiments  directed  towards  demonstration  of 
the  fact  that  diminished  function  of  one  of  the  limbs  may  arise 
through  interference  with  motor  power,  Goltz  sought  to  sustain  his 
opinion  by  another  series  of  experiments — by  section  of  the  pos- 
terior columns  of  the  spinal  medulla,  by  means  of  which  he  believed 
he  could  demonstrate  the  same  motor  disturbances  of  walking  as 
appear  on  destroying  the  motor  zone  of  the  cerebral  cortex.  If  from 
this  experiment,  then,  it  should  be  deducted  that  destruction  of  the 
posterior  columns — which  are  the  paths  of  transmission  of  cutaneous 
sensibility — produces  phenomena  analogous  to  those  produced  by 
destruction  of  that  zone  of  the  cerebral  cortex  known  as  the  motor 
zone,  such  zone  ought  to  be  retained  as  the  central  station  of  the 
posterior  columns,  and  hence  a centre.*  Further,  according 

to  Schiff,  the  result  of  destruction  of  the  so-called  motor  zone  is  not  a 
motor  paralysis,  but  simply  an  ataxia  resulting  from  abolition  of  the 
cutaneous  sensibility  of  the  respective  limbs.  The  doctrine  by  which 
the  so-called  motor  centres  ought  not  to  be  retained  as  motor, 
properly  speaking,  but  as  centres  of  sensibility,  or  representative  of 
movements  whose  true  motor  nuclei  would  be  located  in  the  bulb 
or  elsewhere,  has  been  supported  by  many  experimenters.  Hitzig 
expresses  the  opinion  that  the  disturbances  of  voluntary  movements 
resulting  from  extirpation  of  the  motor  zone  are  the  expression  of 
disturbances  of  the  representative  activity — that  is  to  say,  of  the 
suppression  of  the  motor  images  of  the  various  movements.  If  such 
images  be  wanting,  the  movements  can  no  longer  be  represented, 
and  either  are  not  fulfilled  or  are  defective. 

Munk  expresses  almost  the  same  opinion.  He  merely  gives  ex- 
pression, on  a larger  experimental  basis,  to  the  same  idea  as  Hitzig. 
The  motor  zone,  according  to  Munk,  forms  a part  of  the  sensory  zone, 
which  is  much  more  extensive.  The  destruction  of  this  sensory 
sphere  (according  to  Hitzig,  Munk,  etc.)  produces  functional  defects, 
which  have  reference  to  the  various  forms  of  sensibility  of  the  different 
regions  of  the  body.  The  ideas  or  images  of  contact,  pressure,  and 
temperature,  formed  by  means  of  elementary  cutaneous  sensations, 
may  be  lost  ; or  we  may  have  suppressed  the  images  of  the  positions 
in  space  of  the  diverse  parts  of  the  body,  formed  by  cutaneous, 
muscular,  articular,  and  aponeurotic  sensations,  and  by  the  con- 
sciousness of  muscular  innervation.  The  movements,  determined  by 
discharges  of  the  true  motor  centres  at  the  base  of  the  brain,  project 
themselves  on  the  cerebral  cortex  as  images  of  completed  move- 

* It  is  also  true  that,  about  twenty  years  later,  Hosel,  Flechsig,  and 
others  were  able,  on  different  grounds,  to  state  that  the  fillet  of  Reil  reaches 
the  motor  zone. 


PHYSIOLOGY  OF  THE  MOTOR  AREA 


III 


ments,  so  that,  on  the  cortex  of  the  brain,  there  do  not  exist  true 
motor  centres,  but  centres  of  motor  images,  the  elements  for  which 
are  all  of  a sensory  nature.  The  destruction  of  such  a sensory 
sphere  does  not  determine  a true  motor  paralysis,  because  the  dis- 
turbances of  motion  depend,  according  to  Munk,  on  loss  of  memory 
of  the  motor  images,  through  which  loss  there  is  no  longer  possible 
the  representation,  in  the  consciousness,  of  the  symbols  of  existence, 
of  the  position,  and  of  the  muscular  attitudes  of  the  paralyzed  parts. 
According  to  the  idea  which  we  hold  to-day  concerning  reflexes,  the 
doctrine  of  Munk  resembles,  on  general  lines,  that  of  Hitzig,  as  well 
as  that  of  Francois  Frank,  who  considers  the  movements  deter- 
mined by  excitation  of  the  respective  points  of  the  so-called  motor 
zone,  analogous  to  reflexes,  with  this  difference,  that  the  ordinary 
reflex  is  provoked  by  a cutaneous  stimulation,  while  those  of  which 
we  have  been  speaking  are  provoked  by  cortical  stimulation.  Ac- 
cording to  Tamburini  and  Luciani,  the  so-called  motor  zone  is  a 
mixed  one,  and  contains  throughout  both  motor  and  sensory 
elements.  Hence  arose  the  conception  of  the  senso-motor  zone, 
which  united  the  doctrine  of  Hitzig  and  Schiff  with  that  of  Ferrier, 
who  maintained  the  exclusively  motor  nature  of  the  zone  in  question. 
Luciani,  in  particular,  insisted  in  his  writings  that  the  motor  centres 
and  the  centres  of  sensibility  which  concurred  in  the  fulfllment  of  a 
complex  function  were  intermingled,  or  very  close  to  one  another,  in 
the  cerebral  cortex.  In  this  way  the  effects  ensuing  from  the  de- 
struction of  a giv(m  part  of  the  senso-motor  zone  consist  of  paralysis 
or  paresis  of  movement,  and  of  a more  or  less  distinct  disturbance 
of  sensibility.  This  doctrine  found  confirmation  in  the  important 
clinical  researches  of  Seppilli  and  the  histological  ones  of  Golgi,  who, 
in  a memorable  article,  upheld  the  uniform  senso-motor  function  of 
the  cerebral  cortex,  throughout  which  we  find,  in  close  proximity, 
motor  and  sensory  corpuscles.  According  to  Luciani,  the  senso- 
motor  zone  is  not  limited  merely  to  the  Rolandic  region,  but  extends 
considerably  as  a zone  interlocked  behind  with  the  visual  area  and 
in  front  with  the  frontal  lobe.  Just  as  this  zone  contains  sensory 
elements  for  the  muscles  of  the  limbs,  so  the  visual  zone  contains 
sensory  elements  for  the  retina  and  motor  elements  for  the  muscles 
of  the  eyes,  and  similarly  with  other  sensory  zones.  The  removal 
of  the  whole  motor  zone,  or  a part  of  it,  revealed  to  Luciani,  as  to 
Hitzig,  Schiff,  and  others,  marked  defects  of  tactile  sensibility  and, 
in  a less  degree,  of  the  sense  of  pain  and  muscular  sense  (muscular 
consciousness). 

According  to  Bechterew’s  latest  observations  also,  the  so-called 
motor  zone  is  at  once  sensory  and  motor.  By  experimenting  on  the 
monkey,  he  came  to  the  conclusion  that  with  disturbances  of  motion 
there  are  constantly  associated  disturbances  of  cutaneous  and  mus- 
cular sensibility.  In  this  senso-motor  zone  the  muscular  and 
cutaneous  sensations  are  found  co-ordinated  with  determinate  move- 


II2 


PSYCHIATRY 


ments.  This  doctrine  of  Bechterew  differs  from  that  which  the 
famous  physiologist  of  Petersburg  had  expressed  in  previous  publica- 
tions, wherein  he  then  held  that  the  really  motor  zone  was  found 
very  near  to,  but  not  mixed  with,  the  zone  of  cutaneous  and  muscular 
sensibility,  and  that  the  latter  was  situated  immediately  behind  the 
true  motor  zone,  which  would  have  for  its  seat  the  anterior  part  of 
the  sigmoid  gyrus  in  the  dog,  corresponding  to  the  anterior  Rolandic 
convolution  in  man,  while  the  sensory  area  would  occupy  the  pos- 
terior part  of  the  sigmoid  gyrus  corresponding  in  man  and  in  the 
monkey  to  the  posterior  Rolandic  convolution.  Notwithstanding 
this,  Bechterew  holds  that  the  parietal  lobe  remains  always  the  most 
conspicuous  centre  of  sensibility,  extending  also  in  front  upon  the 
true  motor  zone. 

In  opposition  to  this  doctrine,  which  considers  the  so-called  motor 
zone  as  sensory,  in  the  sense  of  Hitzig  and  Munk — that  is,  as  a zone 
of  motor  images  projected  upon  the  cortex  and  exciting  the  under- 
lying motor  centres — and  in  opposition  to  the  other,  which,  accord- 
ing to  Tamburini,  Luciani,  and  Bechterew,  teaches  that  such  a 
zone  is  composed  of  motor  and  sensory  elements,  placed  promis- 
cuously in  the  same  cortical  area  for  the  individual  regions  of  the 
body,  stands  the  doctrine  of  Ferrier,  according  to  which  the  motor 
zone  is  exclusively  a centre  of  departure  of  the  motor  excitations  for 
the  individual  muscular  regions  of  the  body,  entirely  distinct  from 
the  centres  of  common  and  muscular  sensibility,  which,  according 
to  him  and  his  pupils  Horsley  and  Schafer,  have  their  seat  in  the* 
limbic  lobe — the  convolution  of  the  hippocampus  and  that  of  the 
corpus  callosum.  Ferrier  holds  that  there  is  no  relation  between  the 
degree  of  alteration  of  sensibility  and  that  of  motor  paralysis  ; that 
the  motor  centres  of  the  cortex  are  anatomically  different  from  the 
centres  of  general  and  special  sensibility,  and  that  the  various  forms 
of  cutaneous  and  muscular  sensibility  can  be  profoundly  disturbed 
or  abolished,  at  least  temporarily,  by  destruction  of  the  region  of  the 
hippocampus,  the  result  varying  in  degree  and  duration  according  to 
the  extent  and  depth  of  the  lesion,  without  there  being  any  accom- 
panying paralysis.  The  idea  that  the  sensory  centres,  including 
that  of  cutaneous  sensibility,  were  distinct  from  the  motor  centres 
was  strenuously  defended  by  Horsley  and  Schafer,  who  found  that 
extensive  lesions  of  the  gyrus  fornicatus  produced  a remarkable  and 
persistent  anaesthesia  in  the  whole  of  the  opposite  side  of  the  body. 
The  centres  for  the  ideas  of  a movement,  according  to  Ferrier,  have 
a different  seat  from  that  of  the  true  motor  centres,  destruction  of  the 
latter  paralyzing  the  power  of  execution,  not  the  ideal  conception  of 
the  movement  itself. 

After  the  extension  of  localization  of  sensibility  from  the  hippo- 
campus alone  to  the  convolution  of  the  corpus  callosum,  as  the  result 
of  the  experiments  of  Horsley  and  Schafer,  Horsley,  by  another  series 
of  experimental  proofs,  was  obliged  to  admit  that  the  so-called  motor 


PHYSIOLOGY  OF  THE  MOTOR  AREA 


113 

zone  is  also  the  seat  of  kinaesthetic  sensations  ; that  by  circum- 
scribed lesions  of  the  motor  zone  there  can  also  be  made  apparent 
disturbances  of  tactile  sensibility  ; and  that  tactile  sensibility  (the 
faculty  of  localizing  tactile  sensations),  the  muscular  sense,  and  the 
representation  of  the  voluntary  movements,  exist  together  in  the 
Rolandic  zone. 

Before  proceeding  further,  it  is  well  to  determine  what  is  a 
volitio7'ial  movement,  because  one  can  understand  how  great  a diffi- 
culty there  may  be  in  defining  it,  if,  given  a cortical  lesion,  we  may 
have  indeed  to  deal  with  a sensory  disturbance,  an  intellectual  dis- 
turbance, or  a motor  disturbance,  such  as  arises  from  the  section  of  a 
motor  nerve  or  from  a lesion  of  the  spinal  medulla.  A volitional 
movement  results  from  many  elementary  components.  If  I extend 
my  hand,  this  act,  which  seems  a functional  unit,  a simple  phe- 
nomenon, a fiat,  can  be  resolved  into  diverse  elementary  factors. 
In  every  volitional  movement,  in  fact,  we  can  distinguish — (i)  the 
image  of  the  object  which  is  to  be  accomplished,  seeing  that  there 
must  be  represented  to  one’s  self  the  purpose  of  the  movement, 
otherwise  it  would  not  be  intentional ; (2)  the  image  of  the  movement 
which  we  have  to  effect,  in  order  to  attain  the  end  in  view  ; 
(3)  the  moment  in  which  we  determine  to  fulfil  the  said  movement, 
which  can  be  expressed  in  a single  word — fiat — (What  this  fat  is  has 
not  been  determined  by  all  in  the  same  manner,  and  it  is  perhaps 
not  easy  to  comprehend.  To  satisfy  the  inquiring  mind,  however, 
let  us  consider  it  as  a state  of  tension,  the  highest  degree  of  the 
sensorial-emotional  tension  which  finds  its  consummation  in  the 
correlative  act)  ; (4)  the  nervous  discharge,  the  calling  into  play  of 
a group  of  muscles  to  accomplish  the  said  movement,  which  corre- 
sponds exactly  to  the  image  representative  of  it ; (5)  the  conscious- 
ness of  the  movement  completed,  otherwise  the  registration  of  the 
image  in  the  cerebrum,  in  relation  to  the  whole  personality 
executing  the  desired  movement. 

The  volitional  movement  once  shown  to  be  impossible  otherwise 
than  as  dependent  on  the  concurrence  of  all  these  images  or  the 
psychic  components  of  some  of  them,  it  is  easy  to  understand  how 
the  physiologists,  confronted  by  the  motor  disturbance  which 
happens  whenever  any  of  these  components  are  wanting,  particularly 
the  second  and  fourth,  have  attributed  the  paralysis  sometimes  to 
failure  of  the  sensory  component— the  image  of  the  movement— and 
sometimes  to  that  of  the  motor  component — i.e.,  the  cortical  motor 
discharge.  Thus,  we  have  explained  how  it  is  that  some  have  denied 
the  character  of  motor  to  those  centres  discovered  on  the  cortex 
of  the  cerebrum,  judging  them  to  be  psychic  centres  where  motor 
images  are  registered  ; these  being  suppressed,  the  movement  can 
no  longer  be  effected.  But  others,  like  Terrier,  have  vigorously 
maintained  that  in  the  case  in  question  we  have  to  deal  with  a true 
motor  disturbance,  with  a loss  of  power  varying  in  degree  according 

8 


PSYCHIATRY 


1 14 

as  the  destruction  of  the  cortical  centres  is  more  or  less  extensive. 
Others,  again,  like  Luciani,  Tamburini,  Horsley,  and  Bechterew, 
have  arrived  at  the  conclusion  that,  in  that  excitable  zone  of  the 
cerebral  cortex,  motor  centres  are  commingled  with  sensory  centres  ; 
consequently,  its  destruction  produces  diminution  both  of  motor 
energy  and  of  sensibility. 

After  frequent  returns  to  the  study  of  the  subject,  I feel  that  I 
cannot  share  Munk’s  opinion  that  that  part  of  the  cerebral  cortex 
is  merely  a centre  of  sensory  images  of  movements.  It  represents 
generally,  if  not  exclusively,  a cortical  motor  centre  in  the  strictest 
sense,  as  is  proved  from  two  sets  of  data  furnished  by  experiments  on 
animals  and  clinical  observation.  These  sanction  the  statement  that 
after  the  removal  of  the  motor  zone  the  animal,  notwithstanding  a 
degree  of  locomotion,  cannot  perform  certain  specialized  movements. 
A dog  accustomed  to  give  its  paw,  after  mutilation  produced  experi- 
mentally in  the  excitable  area  of  the  cerebral  cortex,  strives  to  do  so, 
but  does  not  succeed.  If  movement  on  the  sound  side  of  a monkey 
be  prevented,  and  a bunch  of  grapes,  of  which  he  is  very  fond,  be 
offered  him,  he  strives  to  seize  it  with  the  paralyzed  hand,  uses  all 
his  strength  to  reach  the  grapes,  makes  attempts  at  movement,  or 
manages  partial  movement,  but  succeeds  only  when  the  sound  side 
is  liberated.  Thus,  the  image  of  the  object  he  has  in  view  is  not 
lacking  ; indeed,  it  is  very  doubtful  if  the  motor  image  be  wanting, 
seeing  that  the  movement  is  completed  in  part,  though  undeniably 
there  is  defect  in  power,  for  which  reason  the  movement  is  incom- 
plete. 

As  far  as  direct  evidence  goes,  all  that  one  can  demonstrate  in 
dogs  is  that  the  limbs  on  the  side  opposite  to  the  mutilated  hemi- 
sphere are  weakened.  When  we  suspend  by  the  trunk  a dog  whose 
motor  area  has  been  destroyed,  it  assumes  each  time  the  same  posi- 
tion of  extension  of  the  anterior  and  posterior  limbs,  on  the  side 
opposite  to  the  lesion.  When  the  limb  in  connection  with  the  sound 
hemisphere  is  stimulated,  it  becomes  voluntarily  retracted  and  flexed, 
while  the  other  remains  extended ; sometimes,  in  fact,  the  more 
intense  the  stimulation  the  greater  the  extension  of  the  limb.  No 
doubt,  sometimes  movements  are  effected  under  certain  conditions, 
which,  however,  I believe  I can  satisfactorily  determine. 

If  the  cerebral  decortication  be  limited  in  extent,  and  there  be 
spared  a part  of  the  motor  zone,  absolute  or  relative,  the  immobility 
of  the  limb  is  not  so  profound  as  in  dogs  in  which  the  decortication 
has  been  more  extensive.  Thus  only,  in  the  case  of  the  dogs  experi- 
mented on  by  Schiff,  can  one  interpret  the  possibility  of  voluntarily 
offering  the  paw.  The  zone  undestroyed  takes  up  the  function  lost 
through  the  traumatism,  and  makes  good  that  of  the  small  area 
removed. 

Analogous  movements  are  observed  even  when  the  motor  zone 
is  completely  excised,  either  following  upon  repeated  and  more 


PHYSIOLOGY  OF  THE  MOTOR  AREA 


115 

intense  stimulation  of  the  paw  or  in  association  with  movements  of 
the  sound  limb  when  the  animal  is  in  no  way  restrained.  I do  not 
know  how  I could  represent  the  mechanism  of  the  partial  movement, 
if  from  a cortical  lesion  the  image  of  the  movement  itself  should  be 
wanting.  But  I am  pleased  to  report  here  what  I have  had  an  oppor- 
tunity of  observing  in  other  experiments.  If  a dog  operated  upon 
be  placed  on  the  edge  of  a table,  with  the  sound  half  of  its  body  in 
such  a position  that  the  unaffected  limbs  are  folded  under  the  trunk 
in  a state  of  complete  immobility,  while  the  side  opposite  to  the 
cortical  lesion  projects  from  the  table  with  the  corresponding  limbs 
in  a pendant  position,  it  will  be  found  that  the  animal  makes  not 
the  slightest  movement  with  these  limbs,  though  the  position  be  far 
from  comfortable.  When,  however,  it  is  placed  with  the  sound  side 
projecting  from  the  edge  of  the  table,  it  makes  every  effort  with  the 
corresponding  limbs,  hanging  and  free,  to  find  a point  of  resistance, 
even  be  it  the  edge  of  the  table,  in  order  to  support  itself  and 
rise  from  that  uncomfortable  and  uncertain  position. 

According  to  those  who  uphold  the  sensory  or  psychic  nature  of 
the  motor  zone,  the  immobility  in  such  cases  as  above  ought  to 
depend  either  on  the  diminution  or  abolition  of  the  tactile  sense  in 
the  limbs  believed  to  be  paralyzed,  because  they  do  not  respond  to 
any  tactile  or  painful  stimulus  whatever,  as  when  the  hair  is  torn 
from  the  dorsum  of  the  paw,  or  else  on  the  failure  of  the  reproduction 
of  the  images  of  movement. 

But  granted  even  that  there  may  be  defect  of  tactile  sensibility, 
why  should  abolition  of  movement  result  from  it,  if  the  dog  in  the 
experiment  remain  with  its  eyes  open  ? If  we  might  judge  by 
analogy,  we  would  be  compelled  to  absolutely  deny  the  above 
interpretation,  because  in  no  case  in  man  does  anaesthesia  produce 
abolition  of  movement.  Hysterical  women  affected  with  profound 
hemianaesthesia  perform,  with  the  aid  of  sight,  the  most  delicate 
movements  with  the  anaesthetic  limbs,  such  as  those  necessary  in 
playing  the  piano  ; and  I do  not  know  of  a single  case  in  which,  the 
sight  remaining  intact,  alteration  of  sensibility — no  matter  of  what 
nature,  and  from  whatever  pathological  process — has  had  as  a con- 
sequence the  complete  abolition  of  movement.  The  resulting  move- 
ment would  at  most  be  inco-ordinated,  but  not  completely  abolished, 
because  sight  ought,  at  least  in  part,  to  supply  the  place  of  the  tactile 
sense  in  accomplishing  the  movements  ; and  if  sight  do  not,  the  motor 
images  furnished  by  the  healthy  hemisphere  should  supply  those  of 
the  mutilated  one.  It  would  be  rather  strange  were  we  to  interpret 
the  facts  observed  in  animals  in  a manner  quite  different  from  that 
adopted  in  the  case  of  man. 

That  the  dog,  when  stimulated,  does  not  react  by  moving  its 
paws  may  very  likely  depend  upon  the  abolition  of  voluntary 
movement,  by  which  alone  we  can  judge  whether  or  not  the  animal 
has  heeded  a stimulus  from  which  it  seeks  to  liberate  itself.  In 

8 — 2 


ii6 


PSYCHIATRY 


fact,  in  man,  in  ordinary  hemiplegia  without  sensory  disturbances, 
or  even  when  these  are  not  marked,  we  can  stimulate  the  paralyzed 
limb  in  any  manner,  yet  without  the  individual  being  able  to  with- 
draw himself  from  the  position  taken  up  and  from  the  stimulus 
which  irritates  him.  He  is  able,  all  the  same,  to  express  his  sensa- 
tions by  signs  or  by  speech  ; but  if  he  be  excluded  from  these  two 
paths  of  communication  with  our  judgment,  and  if  we  could  imagine 
him  in  the  same  condition  as  the  dog,  we  would  confound  in  man, 
also,  a motor  with  a sensory  disturbance. 

The  affected  limbs  of  those  animals  placed,  as  before  mentioned, 
on  the  edge  of  a table  or  chair  are  found  to  be  not  only  quite  immobile, 
but  also  contracted  ; they  become  rigid  in  a position  of  extension. 
The  tactile  stimuli  applied  to  them  augment  the  rigidity  ; only  by 
the  use  of  force  can  they  be  passively  flexed,  and,  if  permitted,  they 
return  immediately  to  their  former  position.  On  palpation,  all  the 
muscles,  particularly  those  of  the  antero-external  region  of  the 
anterior  limb,  are  found  somewhat  tense  and  prominent  from  con- 
traction. Such  a state  of  the  paretic  limbs  is  certainly  closely 
analogous  to  that  of  the  posthemiplegic  contraction  in  man,  only 
the  degree  of  it  is  different  in  proportion  to  the  degree  of  develop- 
ment of  the  cortical  motor  centres  of  the  dog  as  compared  with  those 
of  man. 

We  frequently  meet  with  cases  where  men  with  limited  cortical 
or  subcortical  lesions  present  slight  paretic  manifestations  in  a 
limb  which,  however,  can  be  adapted,  in  a kind  of  way,  to  fulfil  all 
ordinary  requirements,  but  which  now  lacks,  on  account  of  the 
lesion,  the  agility  and  elasticity  of  a normal  limb  ; yet,  when  an 
extra  effort  is  made,  the  limb,  especially  the  hand  and  fingers,  shows 
a tendency  to  rigidity.  All  patients  in  those  conditions  show  the 
contracture  in  the  superior  limb  more  clearly  when  they  are  asked 
to  grasp  an  object  tightly  in  their  hand — e.g.,  the  dynamometer. 

The  animal  which  has  suffered  mutilation  of  the  motor  zone 
does  not  respond  with  movements  to  tactile  stimuli,  because  it  is  i 
paralyzed  ; nor  does  a man  ever  respond  by  movement  to  tactile  j 
stimuli  applied  on  the  side  of  a hemiplegia  except,  when  the  paralysis  ; 
is  very  slight.  If  the  dog  has  no  other  way  of  expressing  its  sensa-  , 
tions  than  by  corresponding  movements,  we  cannot  infer  that 
sensibility  is  absent  when  the  movement  is  unaccomplished.  All 
that  we  can  logically  and  definitely  determine,  on  the  side  of  the 
more  or  less  subjective  interpretation  of  the  phenomenon,  is  that 
state  of  almost  absolute  immobility,  with  rigidity,  of  the  paretic 
limbs  in  the  conditions  indicated  above,  and  this  is  not  sufficient  j 
to  end  the  discussion.  With  regard  to  this  subject,  I wish  to  refer  ! 
here  to  one  of  the  many  facts  I have  obseived  in  connection  with  | 
dogs  which  have  suffered  mutilation  of  a portion  of  the  brain,  and  ; 
which  1 extract  from  the  register  of  my  experiments.  A bitch,  I 
some  time  previously  under  experiment,  but  apparentlj^  recovered,  j 


PHYSIOLOGY  OF  THE  MOTOR  AREA 


117 

comes  in  heat  ; one  of  the  dogs  from  which  I had  a few  weeks  pre- 
viously removed  the  motor  zone  of  the  left  hemisphere,  and  which 
also  seemed  to  have  recovered,  attempts  to  cover  her.  He  raises 
himself  on  his  hind -legs  properly,  but,  at  the  very  moment  when 
with  the  left  anterior  limb  he  embraces  the  female  by  flexing  his 
paw  under  her  thorax,  the  right  anterior  limb  remains  at  first  rigid 
and  extended,  simply  pressed  against  the  trunk  ; then  in  proportion 
as  the  sexual  excitement  increases,  the  contracture  of  that  limb 
increases.  It  then  slips  rigidly  along  the  trunk  of  the  female  in 
forced  adduction,  reaches  the  gluteal  region  of  the  bitch  in  such  a 
manner  that  it  slips  rigidly  inwards  and  downwards,  and,  inasmuch 
as  the  position  of  the  male  is  untenable,  the  act  is  frustrated.  These 
attempts  are  repeated  with  the  same  result  several  times  in  suc- 
cession. 

In  all  this  effort  on  the  part  of  the  dog  to  effect  coitus,  not  only 
does  he  give  no  sign  of  a volitional  movement  with  the  rigid  limb, 
however  conceivably  slight,  and  not  only  is  he  unable  to  adapt  it  for 
grasping  the  trunk  of  the  female,  but  he  can  never  prevent  the 
rigid  limb,  withdrawn  from  the  control  of  the  will,  from  following 
the  fatal  direction  induced  by  the  contracture,  and  subtly  impeding 
the  fulhlment  of  the  act.  When  has  a disturbance  of  sensibility  in 
man  given  rise  to  phenomena  such  as  these  ? Even  in  the  gravest 
anaesthesia  from  a lesion  of  the  capsule  some  movements  are  always 
possible,  except  when  the  lesion  extends  also  to  the  motor  bundle ; 
vice  versa,  lesions  of  the  motor  bundle  give  complete  paralysis  even 
when  sensation  is  preserved,  which  condition  in  dogs  can  be  con- 
firmed only  by  comparative  observations  in  man. 

As  regards  the  clinical  facts,  it  is  certain  that  every  cortical 
lesion  of  the  motor  zone  of  the  cerebrum  of  man  produces  im- 
mediately paralysis  of  one  or  both  limbs  on  the  side  opposite  to  the 
damaged  hemisphere.  But  while  this  fact  is  constant,  defect  of 
sensibility  is  not  equally  so.  Many  observations  are  recorded  in 
which  disturbance  of  sensibility  has  been  noted  following  upon 
lesions  of  the  motor  zone,  and  no  one  can  disregard  the  value  of 
the  facts  collected  by  Pitrine,  Seppilli,  and  many  others  ; but  there 
are  some  cases,  also,  on  record  in  which  tactile,  muscular,  thermal, 
and  pressure  sensations  were  preserved,  while  there  existed  paralysis 
of  motion  alone.  I even  hold  that  such  cases  occur  more  frequently 
than  recorded,  and  contend  that  it  is  a bad  method  to  collect  and 
select  only  such  as  accord  with  a preconceived  theory. 

A second  argument  in  support  of  the  prevailing  motor  function 
of  the  zone  mentioned  I cull  from  another  order  of  observations 
which  I have  been  able  to  make  in  some  cases  of  Jacksonian  epilepsy. 
Granted  that  all  the  muscular  groups  are  represented  in  the  cerebral 
cortex,  it  follows  from  this  that  excitation  of  a given  zone,  produced 
experimentally  or  provoked  by  an  irritative  process,  should  result 
in  contraction  of  that  muscular  group  whose  cortical  centre  is 


ii8 


PSYCHIATRY 


excited  or  irritated.  Before  the  motor  centres  were  discovered  by 
experiment,  it  had  been  noticed  that  certain  non-destructive  lesions 
of  the  motor  zone,  such  as  small  tumours,  small  cysts,  and  especially 
gummata  having  their  seat  in  the  meninges  over  the  motor  zone, 
could  from  time  to  time  produce  nervous  discharges  to  muscular 
groups  corresponding  to  the  irritated  motor  centres  in  such  a manner 
that  if  the  lesion  corresponded  with  the  centre  of  the  lower  limb 
the  clonic  contractions  commenced  in  that  limb  ; if  with  the  upper 
limb  centre,  then  the  contractions  commenced  in  the  upper  limb — 
e.g.,  in  the  hand  or  some  of  the  fingers.  We  can  always  produce  at 
will  contractions  of  determined  groups  of  muscles  by  exciting  with 
electricity  now  one  point,  now  another,  of  the  cerebral  cortex,  and 
we  can  determine  a priori  what  muscular  groups  will  be  affected 
by  the  clonic  contractions.  If  there  were  truth  in  the  theory  of 
those  who  maintain  that  we  are  not  dealing  with  irritation  of  a truly 
motor  centre,  but  of  a sensory  centre,  or  if  it  were  true  that  it  is 
the  senso-motor  image,  the  tactile,  or  that  of  muscular  sense,  which 
is  reawakened  by  exciting  the  cerebral  cortex,  we  ought  to  note 
what  is  observed  every  time  any  other  sensory  zone  is  excited. 

If  we  excite  the  visual  sensory  zone  we  reproduce  experimentally 
visual  images.  In  man  it  has  been  possible  to  observe,  when 
dealing  with  a non-destructive  lesion  of  the  visual  area,  the 
spontaneous  reawakening  of  images  of  colours,  lights,  scintillations, 
figures,  etc. 

Excitation  of  the  motor  zone  should  produce  corresponding 
tactile  or  muscular  images — in  other  words,  true  senso-motor  hallu- 
cinations. Such,  however,  happens  only  sometimes.  Several  patients 
with  Jacksonian  epilepsy  have  never  admitted  true  hallucinations 
of  touch  or  of  movement.  They  have  only  felt  the  spasm  ; their 
consciousness  has  always  been  surprised  by  the  involuntary  con- 
traction and  by  the  sensation  of  spasm  induced  by  the  contraction. 
There  are  very  few  cases  in  which  the  movement  is  preceded  or 
accompanied  by  cutaneous  and  muscular  sensations. 

Another  argument  calculated  to  show  that  the  Rolandic  zone 
is  a cortical  motor  area  is  that  from  it  emerges  a bundle  of  centri- 
fugal nerve  fibres.  Now,  we  know  of  no  centrifugal  nerve  fibres 
that  are  not  motor  : the  sensory  fibres  are  all  centripetal. 

Seeing  that  in  the  cell  strata  of  the  Rolandic  zone  we  find,  as 
throughout  the  cortex,  both  motor  and  sensory  cells  (Golgi,  Cajal), 
we  can  suppose,  not  without  some  probability,  that  the  Rolandic 
zone  may  be  at  one  and  the  same  time  a motor  and  sensory  centre. 
Nevertheless,  from  the  facts  set  forth  above,  we  should  also  hold 
that  the  sensory  area  does  not  coincide  exactly  with  the  motor  area, 
but  extends  upon  the  parietal  and  the  limbic  lobes. 

The  motor  centres  are  divided  into  two  sections  : one 
more  central,  which  we  may  consider  as  the  centre  of  the  move- 
ments of  preservation  and  defence  in  the  individual — a centre  of 


PHYSIOLOGY  OF  THE  MOTOR  AREA 


119 

greater  functional  intensity — and  a neighbouring  zone  which  may  be 
regarded  as  an  evolutive  motor  zone. 

The  centre  of  greater  intensity  is  found  on  the  two  Rolandic 
convolutions,  especially  on  the  anterior,  while  the  evolutive  motor 
zone  extends  more  in  front.  In  the  latter  the  common  motor 
function  is  weaker,  mixes  with  other  functions,  and  has  a tendency 
to  become  more  intellectual,  as  we  shall  see  in  the  sequel.  It  is 
very  probable  that  it  serves  as  an  anatomical  substratum  to  the 
development  of  motility  in  relation  to  human  progress  (writing, 
special  and  delicate  handicrafts,  the  manipulation  of  musical  instru- 
ments, etc.).  It  is  found,  in  front,  at  the  foot  of  the  frontal  con- 
volutions ; behind,  it  extends  to  the  ascending  parietal  and  the 
superior  and  inferior  parietal  convolutions,  where  the  motor  function 
gradually  diminishes  and  the  sensitive  and  sensory  prevails.  The 
motor  zone  is  hypothetically  divided  into  different  areas,  each  of 
them  in  strict  relation  to  a given  muscular  region  (see  Chapter  L, 
p.  61). 

Still,  the  various  cortical  centres  for  the  different  muscular 
regions  are  only  centres  of  greater  functional  intensity  for  the 
respective  muscular  groups,  which  are  in  reality  represented  by  a 
much  more  extensive  zone  on  the  cortical  areas  for  the  two  limbs. 
Indeed,  a close  observation  permits  us  to  consider  as  inadmissible 
the  conception  of  monoplegia  in  the  strictest  sense  of  the  word. 

There  are  no  precise  limits  either  to  the  motor  zone,  taken  in  its 
entirety,  or  to  the  individual  centres  of  the  various  muscular  regions. 
The  former  is  fused  with  the  zone  of  development  in  front  and  with 
the  sensory  area  behind  ; the  latter  are  blended  in  a great  inter- 
mingling with  one  another,  and  with  the  surrounding  zone,  a fact 
which  affords  an  explanation  of  functional  compensation.  It 
frequently  happens,  in  fact,  that  we  observe  that  the  motor  and 
sensory  disturbances  caused  by  destruction  of  an  area  of  the  cerebral 
cortex  disappear  after  a time. 

To  Goltz  has  been  given  the  credit  of  drawing,  more  strenuously 
than  any  other,  the  attention  of  physiologists  to  this  fact.  No  matter 
in  what  point  of  the  cerebral  cortex  a lesion  is  situated,  two  orders 
of  phenomena  will  result : (i)  Phenomena  depending  on  the  state 
of  temporary  arrest  in  the  surrounding  parts,  and  sometimes  also 
in  parts  distant  from  the  site  of  destruction  ; (2)  phenomena  of 
absolute  defect — what  yet  remains  definitely  awanting  after  restora- 
tion of  the  above.  This  is  true  in  the  case  of  animals,  and  much 
more  so  in  man.  If  an  individual  is  struck  by  an  apoplectic  attack 
due  to  cerebral  haemorrhage,  embolism,  thrombosis,  or  if  from  other 
causes  a violent  destructive  lesion  of  the  cerebral  cortex  is  pro- 
duced, there  is  manifested  from  the  outset  a more  or  less  complete 
paralysis  of  one  side  ; but  sooner  or  later  the  profound  paralysis 
disappears,  and  there  remains  a functional  deficiency,  which  goes  no 
further,  and  will  remain  a partial  paralysis,  a disturbance  of  sense, 


120 


PSYCHIATRY 


a hemiopia,  a psychic  disturbance,  etc. — in  fine,  a true  defect,  the 
nature  of  which  depends  on  the  situation  and  extent  of  the  lesion. 
Why  does  the  individual,  completely  paralyzed  at  first,  recover  his 
movements  little  by  little  ? 

Two  hypotheses  may  be  offered  : either  the  most  of  the  initial 
phenomena  were  simply  those  of  arrest,  and,  after  some  time,  the 
brain  having  recovered  from  the  shock  and  from  the  effects  of  the 
collateral  disturbances  of  circulation,  the  function  was  renewed  in 
those  parts  which  had  not  been  destroyed,  but  simply  inhibited  in 
their  function,  or  the  parts  surrounding  the  destroyed  foci  had,  by 
means  of  collaterals,  established  more  direct  relations  with  the 
peripheral  organs,  withdrawn  from  the  influence  of  the  centre  by 
the  lesion,  and,  in  addition,  developed  enough  energy  to  make  good 
the  functional  deficiency  of  the  part  destroyed.  Experimentally, 
I have  noted,  before  others,  that  a dog  in  which  part  of  the  motor 
zone  is  destroyed  presents  in  the  first  days  after  the  mutilation 
a notable  paralysis,  which  after  a time  disappears,  leaving  behind 
nothing  more  than  a more  or  less  sensible  motor  deficiency.  If 
another  portion  of  the  cortex  around  the  first  focus  is  then 
destroyed,  the  paralysis  reappears  and  is  of  greater  duration  ; and 
if,  when  the  animal  has  again  recovered,  the  destroyed  area  is 
enlarged  anew,  the  paralysis  reappears,  more  pronounced  and  more 
permanent  than  formerly.  In  this  case  the  compensation  is  made 
by  the  parts  of  the  cerebral  cortex  surrounding  the  lesion,  which, 
being  homologous,  have  developed  a functionality  primarily  latent, 
but  certainly  due  to  the  efforts  which  the  animal  repeats  in  order 
to  fulfil  those  movements  which  have  been  abolished  (educability 
of  the  zone  of  reserve).  No  one  doubts  any  longer  that  every 
severe  cerebral  lesion  produces  not  only  a loss  of  function,  inherent 
in  the  part  destroyed,  but  also  a condition  of  arrest,  especially  in 
the  more  neighbouring  parts,  on  account  of  which  the  phenomena 
are  more  grave  at  first,  while  later  on,  when  the  functionality  is 
reassumed  by  the  centres  which  have  preserved  their  anatomical 
integrity,  the  clinical  picture  becomes  rather  reduced. 

When  this  does  not  depend  upon  the  disappearance  of  a simple 
condition  of  arrest,  but  upon  recovery  from  the  paralysis,  in  spite 
of  the  existence  of  a small  focus  in  the  motor  zone,  as  happens  very 
frequently  in  dogs,  it  is  to  be  assumed  that  a slow  compensation  has 
been  effected  by  a part  of  the  healthy  surrounding  zone  of  reserve. 
The  parts  surrounding  the  motor  zone  of  greater  functional  intensity, 
though  perhaps  containing  elements  with  other  functional  attributes 
than  those  belonging  to  the  motor  zone,  yet  certainly  contain  at  the 
same  time  motor  elements  which,  by  being  able  to  establish  connec- 
tions with  the  periphery,  can  in  time  assume,  as  the  result  of  exer- 
cise, the  suppressed  functionality,  and  compensate  the  loss  suffered. 

It  is  erroneous  to  maintain  that  the  corpus  striatum  cait  assume 
the  function  of  the  destroyed  motor  zone.  This  is  contradicted  by 


PHYSIOLOGY  OF  THE  MOTOR  AREA 


I2I 


the  fact  that  destruction  of  the  nuclei  of  the  base  (the  caudate  and 
lenticular  nuclei)  does  not  produce  paralysis,  and,  further,  that  the 
corpus  striatum  does  not  assume  relations  with  the  pyramidal 
bundle.  This  view  is  proved  both  experimentally  and  clinically. 

No  one  can  agree  with  the  hypothesis  that  the  cerebellum 
assumes  the  function  of  the  destroyed  cerebral  cortex.  If  it  is 
admissible,  as  Luciani  has  demonstrated,  that  the  motor  zone  may 
in  part  compensate  the  function  of  the  destroyed  cerebellum,  in  so 
far  as  the  voluntary  movements  correct  the  cerebellar  inco-ordina- 
tion by  way  of  the  cerebro-spinal  paths,  the  inverse  by  no  means 
holds  good,  especially  seeing  that  the  cerebellum  (as  I was  enabled 
to  demonstrate)  is  not  at  all  inserted  in  the  course  of  the  pyramidal 
fibres.*  There  only  remains  possible  the  cortical  compensation, 
which  is  furnished  partly  by  the  cerebral  cortex  surrounding  the 
destroyed  area,  and  partly  by  the  cerebral  cortex  of  the  opposite 
hemisphere. 

That  there  may  be  a functional  compensation  by  the  other 
hemisphere  we  deduce  from  the  following  facts  : When  in  an  animal 
recently  paralyzed  on  one  side  from  a lesion  of  one  sigmoid  gyrus, 
but  now  recovered  (at  least  apparently),  we  destroy  the  motor  zone 
of  the  other  side,  there  results  not  only  paralysis  of  the  side  opposite 
to  the  hemisphere  last  injured,  but,  in  addition,  there  is  reproduced 
the  paralysis  of  the  other  side.  This  paralysis  is  much  more  pro- 
found and  permanent  than  that  produced  by  extensive  destruction 
of  the  motor  zone  of  one  side  only. 

The  cerebral  cortex  is  not  merely  the  organ  of  sensations,  move- 
ments, and  the  higher  psychic  functions  : it  is  in  addition  the  higher 
centre  of  all  the  organic  functions.  The  respiration,  the  circulation, 
the  sensations,  and  the  movements  of  the  internal  organs,  are  all 
represented  in  the  cortex  of  the  brain,  in  which  we  have  been  able 
to  recognise  corresponding  excitable  points.  Thus  the  cerebral 
cortex,  being  brought  into  intimate  relation  with  every  organ  and 
tissue,  effects  their  synthesis  and  assumes  their  government. 

Centre  of  Respiration. — Danilewsky  observed  slowing  of  the 
respiration,  with  deeper  inspirations  and  slower  expirations,  by 
exciting  a zone  coinciding  with  that  of  the  facial  nerve  (relations 
between  facial  expression  and  respiration  in  the  affective  states?). 
Munk  places  the  respiratory  centre  in  dogs  in  the  frontal  lobe,  a few 
millimetres  in  front  of  the  chief  frontal  sulcus,  which  would  corre- 
spond in  the  monkey,  according  to  the  experiments  of  the  same 
physiologist,  to  the  prefrontal  sulcus,  with  this  difference,  that  the 

* The  experimental  conclusion  that  the  volitional  motor  paths  do  not 
pass  through  the  cerebellum  has  been  contradicted  by  the  hypothesis  of 
V.  Gehuchten,  as  we  have  seen  in  the  previous  chapter.  Such  a hypothesis, 
however,  is  not  supported  by  incontestable  proof.  New  experimental  and 
anatomical  researches  are  necessary  before  we  can  yet  hold  as  proven  the 
cerebro-ponto-cerebellar  motor  paths. 


122 


PSYCHIATRY 


excitation  (electric)  of  one  point  on  the  horizontal  branch  of  the 
precentral  sulcus  produces  tetanic  inspiration,  the  excitation  of 
another  point  a little  more  external  in  the  same  sulcus  produces 
tetanus  of  the  abdominal  muscles.  According  to  Munk,  then,  the 
centre  of  respiration  is  in  the  frontal  lobe,  in  immediate  relation 
with  the  musculature  of  the  trunk.  Unverricht  and  Preobraschensky 
found  a centre  of  arrest  of  respiration  on  the  third  external  convolu- 
tion in  the  dog,  external  to  the  orbicular  centre.  Bechterew  and 
Ostankow  have  always  found  quickening  of  respiration,  with  greater 
length  of  the  expiratory  phase,  by  exciting  the  anterior  extremity  of 
the  second  external  convolution,  immediately  above  the  centre  for 
the  movements  of  deglutition.  These  diverse  localizations  are,  in 
a measure,  due  to  the  complicated  mechanism  of  respiration,  while, 
on  the  other  hand,  they  give  some  appearance  of  truth  to  the  dictum 
of  Bochefontaine  and  of  Francois  Frank,  according  to  which  excitation 
of  any  point  whatever  of  the  cerebral  cortex  is  followed  by  a modifica- 
tion of  the  respiration.  In  the  course  of  various  researches  on  the 
cortical  centres  I have  never  experimented  directly  on  those  of 
respiration,  but  I believe  that  both  those  who  localize  and  those 
who  do  not  may  be  right. 

I am  convinced  that  all  excitations  of  the  cortex,  in  whatever 
point  they  occur,  modify  the  respiratory  rhythm,  and  that,  on  the 
other  hand,  there  are  zones  in  the  cortex  which  are  in  more  direct 
relation  with  the  muscles  of  respiration.  In  the  first  case  it  is  the 
sensory  products  of  each  cortical  area — evoked  in  the  form  of 
images,  by  electric  excitation — together  with  the  relative  emotional 
states  which  accompany  them,  that  determine  modifications  of 
the  respiration,  variable  according  to  the  animals  experimented 
upon  and  their  ages. 

In  the  second  case  we  have  to  deal  with  direct  relations  between 
certain  cortical  zones  and  the  musculature  concerned  in  the  respira- 
tory acts,  and  it  is  quite  natural  that  there  should  be,  on  the  one 
hand,  a zone  for  inspiration,  and,  on  the  other,  one  centre  for  accelera- 
tion and  another  for  slowing  of  the  respiratory  movements ; still 
further,  that  these  centres  should  be  near  one  another,  and  in  intimate 
relation  with  the  centres  of  physiognomic  expression,  phonation, 
deglutition,  and  that  of  the  muscles  of  the  trunk.  They  are  not 
simple  refiex  centres,  like  those  of  the  floor  of  the  fourth  ventricle, 
but  are  subordinate  on  the  one  hand  to  the  will,  and  on  the  other 
(independently  of  the  will)  to  the  states  of  the  sensory  and  senso- 
motor  areas,  whence  arise  the  affective  states,  which  are  always 
accompanied  by  modifications  of  the  respiratory  rhythm. 

Upon  the  circulation  the  cerebral  cortex  likewise  exercises  its 
regulative  influence.  By  electric  excitation  of  the  motor  area 
Bechterew  and  Mislawski  obtained  acceleration  of  the  pulse  and 
modification  of  the  blood-pressure.  Excitation  of  the  white  sub- 
stance, after  previous  decortication  of  the  said  area,  produced  not 


PHYSIOLOGY  OF  THE  MOTOR  AREA 


123 


only  marked  slowing  of  the  pulse,  but  also,  on  prolonging  the 
excitation,  arrest  of  the  heart  in  diastole.  Evidently,  then, 
the  cortex  exerts  an  influence,  not  only  on  the  blood-pressure, 
but  also  on  the  activity  of  the  heart.  The  researches  carried  out 
for  some  time  by  Tomasini,  in  my  clinique,  partly  confirmed  these 
results. 

Deglutition  and  the  movements  of  the  stomach  and  intestines 
are  likewise  represented  in  the  cerebral  mantle.  The  centre  for 
deglutition  is  situated  on  the  anterior  part  of  the  second  external 
convolution,  outside  of  the  sigmoid  gyrus,  and  in  proximity  to  one 
of  the  respiratory  centres  (Bechterew,  Ostankow)  and  the  centre  for 
movements  of  the  mouth  and  lower  jaw,  besides  that  of  the  tongue. 
The  experiments  of  Kethi  have  demonstrated  the  succession  of 
movements  of  deglutition  to  those  of  mastication  by  exciting  with 
electricity,  in  dogs,  an  area  situated  upon  the  sigmoid  gyrus  in  front 
of  and  external  to  the  centres  for  the  limbs.  The  succession  of  move- 
ments of  deglutition  to  those  of  mastication  ought  to  take  place 
through  anatomical  connections  corresponding  to  the  physiological 
fact.  Kethi  admits,  therefore,  a centre  for  co-ordination  of  the 
movements  of  mastication  and  deglutition.  Such  a centre  might  be 
apparent  from  the  fact  alone  that  the  combined  movements  can 
certainly  be  produced  by  cortical  excitation,  though  in  reality 
dependent  upon  the  inferior  centre,  which  Kethi  and  Bechterew 
have  affirmed  to  be  in  the  posterior  part  of  the  optic  thalamus. 

Further,  in  proximity  to  the  crossed  sulcus  centres  of  movement 
for  the  stomach  are  found.  As  is  well  known,  the  movements  of  the 
cardiac  end  are  opposed  to  those  of  the  pylorus,  in  such  a way  that 
the  opening  of  the  cardiac  end  coincides  with  the  repose  or  with 
constriction  of  the  pylorus,  and,  vice  versa,  the  movements  of  the 
pylorus,  which  are  active  when  the  stomach  is  full,  coincide  with  a 
state  of  inactivity  of  the  cardiac  end. 

Corresponding  to  this  physiological  fact  there  is  found  on  the 
cerebral  cortex,  in  the  neighbourhood  of  the  crossed  sulcus,  a dilator 
centre  of  the  cardiac  end,  excitation  of  which,  by  relaxing  the  cardiac 
end,  determines  contraction  of  the  pylorus.  Vice  versa,  the  excita- 
tion of  the  posterior  and  external  parts  of  the  sigmoid  gyrus  re- 
inforces the  rhythmic  movements  of  the  pylorus  so  far  as  to  determine 
a contraction  of  the  whole  pyloric  region.  The  stimulation  of  the 
antero-external  part  of  the  sigmoid  gyrus  determines  the  contraction 
of  the  cardia  and  the  cardiac  region,  while  the  pyloric  region  remains 
in  a state  of  rest. 

The  faradic  excitation  of  the  posterior  part  of  the  sigmoid  gyrus 
and  of  the  adjacent  posterior  and  external  part  of  the  second  external 
convolution,  according  to  the  experiments  of  Bechterew  and  Mis- 
lawski,  modifies  the  muscular  tone  of  the  intestinal  walls.  Further, 
the  excitation  of  a small  zone  of  the  cortex,  situated  behind  the 
posterior  extremity  of  the  fissure  of  Sylvius,  between  the  occipital 


124 


PSYCHIATRY 


and  the  temporal  lobes,  frequently  induces  contraction  of  the  large 
intestine. 

The  experimental  researches  of  Bochefontaine  first,  and  after- 
wards the  more  recent  ones  of  Bechterew  and  Mislawski,  and  of 
Mosso  and  Pellacani,  have  demonstrated  that  the  movements  of  the 
bladder  likewise  possess  a cortical  centre.  According  to  the  first  of 
those  observers,  such  a centre  is  found  on  the  external  face  of  the 
sigmoid  gyrus  ; according  to  Bechterew  and  Mislawski,  it  is  found 
on  the  internal  or  interhemispheric  aspect  of  the  same  gyrus.  Mosso 
and  Pellacani  have  more  clearly  confirmed  the  existence  of  a cortical 
centre  for  the  bladder. 

The  movements  of  the  sphincter  of  the  anus,  and  even  the  co- 
ordinated movements  of  defaecation,  possess,  like  those  of  the 
bladder,  their  cortical  centres.  This  was  located  by  Sherrington,  in 
the  case  of  the  monkey,  in  a very  circumscribed  area  on  the  posterior 
part  of  the  paracentral  lobule,  the  excitation  of  which  provoked 
movements  of  the  sphincter.  Meyer  located  this  centre,  in  the 
inferior  mammals,  on  the  posterior  convolution  of  the  sigmoid 
gyrus,  at  a greater  distance  from  the  crossed  sulcus.  V.  Duneschi 
placed  it  a little  in  front  of  the  point  indicated  by  Meyer,  while 
Gustavo  Mann,  by  exciting  the  same  cortical  zone  indicated  by  Meyer, 
provoked,  not  isolated  movements  of  the  external  sphincter,  but 
strong  contractions  of  it,  along  with  movements  co-ordinated  for. 
defaecation  and  emission.  The  above  centre  is  in  proximity  to  that , 
for  the  tail.  j 

Bechterew  and  Mislawski  combined  to  delimit  also  a centre  fori 
movements  of  the  vagina.  On  the  contrary,  they  found  two  of^ 
them  : one  excito-motor,  on  the  posterior  branch  of  the  sigmoidt 
gyrus,  and  the  other  of  arrest,  pn  the  tract  of  communication  between' 
the  posterior  and  anterior  branch  of  the  sigmoid  gyrus,  and  some-- 
times  also  on  the  superior  border  of  the  second  external  convolution. 

The  secretions  also  are  influenced  by  the  excitation  of  deter-' 
mined  areas  of  the  cortex.  The  salivary  secretion  has  been  the^ 
object  of  particular  researches  by  Bochefontaine  and  Lepine,  who| 
found  that  faradization  of  the  sigmoid  gyrus  provoked  secretion  ofj 
all  the  salivary  glands,  especially  of  those  on  the  opposite  side.j 
According  to  these  two  authorities,  the  excitable  zone,  capable  of 
provoking  the  salivary  secretions,  extends  to  the  anterior  part  of^ 
the  sigmoid  gyrus  and  to  the  adjacent  parts  of  the  first  and  second 
convolutions.  The  more  numerous  and  accurate  experiments  of 
Bechterew  and  Mislawski,  however,  have  shown  that  the  centre  of 
greater  functional  intensity  for  the  secretion  of  the  salivary  glands 
is  found  on  a small  area  of  the  fourth  external  or  primitive  convolu- 
tion, situated  above  and  in  front  of  the  fissure  of  Sylvius  ; and  that 
the  anterior  region  indicated  by  the  two  preceding  experimenters  does 
not  yield  positive  results,  unless  with  a stronger  excitation.  The 
path  for  transmission  of  such  influence  of  the  cortex  upon  the 


PHYSIOLOGY  OF  THE  MOTOR  AREA 


125 


salivary  glands  would  be,  according  to  the  researches  of  Cristiani, 
that  of  the  sympathetic. 

On  the  internal  aspect  of  the  hemisphere  of  dogs — corresponding 
to  the  anterior  and  posterior  convolutions  of  the  sigmoid  gyrus  in 
man — there  has  been  localized  by  these  same  experimenters  an  area, 
excitation  of  which  provokes  the  secretion  of  tears.  The  stimulation 
of  the  external  face  of  the  hemisphere  has  not  admitted  of  the  recog- 
nition of  any  point  excitation  of  which  would  yield  reliable  results. 
The  stimulation  of  the  above  centre  is  very  quickly  followed  by  a 
profuse  flow  of  tears  from  both  eyes,  but  more  abundantly  from  the 
one  opposite  to  the  excited  hemisphere. 

Of  other  secretions  we  know  little  as  regards  their  relations  with 
the  cerebral  cortex — just  so  much  as  has  been  furnished  by  the  re- 
searches of  Bochefontaine.  He  observed,  on  faradization  of  various 
points  of  the  sigmoid  gyrus,  an  arrest  of  the  functions  of  the  liver 
and  pancreas.  While  before  the  excitation  20  drops  of  bile  per 
minute  trickled  from  the  cannula  inserted  into  the  bile-duct,  none 
was  seen  during  and  for  some  minutes  after  the  excitation.  Further, 
the  pancreatic  secretion  was  greatly  checked  by  electric  stimulation 
of  the  crossed,  as  well  as  the  frontal,  convolution  immediately  in 
front.  Nothing  of  a like  nature  is  known  of  the  cortical  centres  for 
the  mammary  and  other  glands.  This  chapter  of  physiological 
anatomy  is  still  somewhat  poor  ; but  one  can  well  foresee  that  all 
the  glands  may  be  connected,  naturally  indirectly,  with  the  cerebral 
mantle,  which  represents  only  the  ultimate  station  in  relation  to  the 
intermediate  ones  found  in  series  in  the  spinal  medulla,  in  the 
corpora  quadrigemina,  and  in  the  optic  thalamus,  and  that,  in  con- 
sequence, they  must  be  of  considerable  importance  in  their  relations 
with  the  other  regions  of  the  mantle.  On  this  fact  depend  the  well- 
known  modification  of  the  secretions  in  emotional  states  and  the 
representation  in  the  unconsciousness  of  the  work  of  the  glands, 
whence  go  out  nervous  impulses  which  (like  those  of  the  muscles 
and  of  the  other  glands)  help  to  constitute  the  personality  and 
character. 

Does  the  cerebral  cortex  possess  also  an  area  which  regulates  the 
temperature  of  the  opposite  half  of  the  body  ? Experiments  have 
supplied  an  answer  in  the  affirmative.  Those  of  Hitzig  have  not 
been  contradicted.  The  destruction  of  areas  of  the  mantle  corre- 
sponding to  the  motor  zone,  or  adjacent  to  it,  produced  immediately, 
and  before  the  dog  had  revived  or  executed  any  movements,  a great 
increase  of  temperature  in  the  limbs  opposite  to  the  injured  hemi- 
sphere ; such  increase  was  from  iW  to  3°,  and  even  as  high  as  7°,  C. 
Excitation  with  a weaker  current  produced  slight  reduction  of  tem- 
perature up  to  six  points  of  a degree  in  the  opposite  limbs.  The 
results  of  these  experiments  were  confirmed  in  their  general  lines  by 
Eulenburg,  Bechterew,  and  Schuller. 

From  the  fact  that  not  only  the  muscles,  but  also  the  respiratory. 


126 


PSYCHIATRY 


circulatory,  intestinal,  hepatic,  visceral,  and  other  oiganic  functions, 
are  represented  in  the  motor  zone  and  its  neighbourhood,  the 
idea  has  arisen  that  the  sigmoid  gyrus  in  the  dog,  and  the 
Rolandic  convolutions,  together  with  a circum-Rolandic  zone,  in 
the  monkey  and  in  man,  ought  to  be  considered  as  an  area  of  con- 
vergence of  the  nerve  waves  coming  from  all  parts  of  the  body,  or 
at  least  as  a higher  organ  for  the  functions  of  organic  life,  and  a field 
for  the  formation  of  the  physiological  self-consciousness. 

Language 

Alongside  the  sensory  and  motor  function  of  the  brain  we  must 
take  under  examination  another,  which,  in  its  essence,  is  also  sensory 
and  motor,  but  of  an  order  more  akin  to  the  intellectual.  I refer  to 
language,  the  centres  for  which,  as  we  shall  presently  see,  are  found 
towards  the  limits  of  the  sensory  and  motor  areas,  in  the  territory 
of  what  I denominate  the  evolutive  zone. 

Language,  which  from  the  beginning  is  only  an  emotional  reflex, 
has  attained  a very  high  place  among  the  functions  of  the  brain,  and 
has  become  likewise  marvellously  complicated,  as  is  easily  under- 
stood when  one  remembers  that  it  sums  up  all  the  intricate 
mechanism  of  the  functions  of  the  cerebrum.  Such  functional 
complexity  and  so  high  a psychic  value  could  only  result  from  a 
greater  activity  of  the  cortex  of  the  brain,  on  which  the  force 
of  evolution  has  ploughed  up  very  large  and  fertile  provinces,  pre- 
viously uncultivated  ; and  from  the  primitive  and  circumscribed 
plots,  whose  product  was  entirely  insufficient  for  the  ever-changing 
and  intricate  conditions  of  life,  the  same  agency  has  greatly  extended 
and  widened  its  dominions. 

The  fact  that  from  simple  articulate  sounds  language  has  attained 
the  degree  of  development  at  which  we  find  it  to-day  is  proof  in 
itself  that  an  analogous  perfectioning  has  been  realized  in  the 
cerebrum,  which  in  language  unfolds  one  of  its  most  complicated 
functions.  Further,  in  my  opinion  there  can  be  no  doubt  that  this 
progressive  development  has  for  its  base  a successive  differentiation 
of  the  various  zones  which  are  the  organic  substrata  of  the  elementary 
factors  of  which  language  is  composed.  Speech  is  the  product  of  a 
complicated  function,  in  which  co-operate  numerous  psycho-physio- 
logical factors,  and  is  coextensive  with  the  anatomical  basis.  As  the 
expression  of  thought  it  cannot  be  studied  merely  as  a form  and  an 
unfolding  mechanism  of  the  ideas,  but  we  must  also  take  into  con- 
sideration, within  certain  limits,  the  content  itself  of  the  language 
— the  ideas  or  thoughts. 

One  can  affirm  without  fear  of  exaggeration  that  the  study  of 
language  is  the  widest  and  most  difficult  of  all  those  involved  in  the 
elucidation  of  the  cerebral  functions.  In  the  natural  sequence  of 
things,  language  and  thought  have  their  evolutional  histories  closely 


PHYSIOLOGY  OF  LANGUAGE 


127 


linked  together  and  bound  up  intimately  with  many  different  con- 
stituent elements. 

Factors  of  three  orders  enter  into  the  complex  mechanism  of 
spoken  and  written  language  : (i)  The  images  of  the  things,  the  ideas, 
the  concepts,  their  relations,  their  components,  their  manner  of 
succeeding  one  another,  their  derivations  and  compounds,  in  never- 
ending  series — these  are  the  psychic  factors  of  language  ; (2)  the 
words  considered  as  a sensible  form  in  which  the  thought  is  moulded 
— auditory,  visual,  and  kinsesthetic  images,  or  phono-articulatory 
and  phono-viso-graphic  formations,  independent  of  the  ideal  content 
which  they  express,  including  the  mechanism  of  their  formation 
and  the  sensory  and  motor  elements  concerned  therein  ; (3)  the 
phono-respiratory-articulatory  peripheral  or  subcortical  mechanism 
of  spoken  language  and  of  the  movements  of  written  language. 

Language  expresses  ideas,  or  notions  and  emotions,  and  therefore 
possesses  a subjective  as  well  as  an  objective  side.  It  has  the  power 
of  arousing  in  individuals  who  hear  us  and  fully  comprehend  us  the 
same  emotion  (besides  the  notion)  as  we  ourselves  feel.  On  the 
other  hand,  there  is  good  ground  to  believe  that  in  its  earliest 
development  it  has  been  almost  exclusively  emotional,  and  little 
by  little  has  become  more  comprehensive,  serving  to  express  notions 
rather  than  emotions. 

Simple  vowel  sounds,  and  even  the  countenance  and  gesture 
alone,  are  more  than  sufficient  to  express  the  emotional  states  of 
the  mind,  while  it  is  impossible  to  express  notions  other  than  by 
words  which  give  a sensible  form  to  determinate  thought,  whose 
accumulation  and  combination  constitute  the  properly  intellectual 
language,  which  may  possess  a more  or  less  emotional  coefficient. 
The  emotional  language  ever  remains  the  mode  of  communication 
between  animals  (song,  cries)  ; it  is  understood  by  animals  of  the 
same  species,  being  capable  of  producing  like  emotions  in  all  of 
them.  Here  is  an  example  : A swallow,  finding  its  nest  occupied 
by  a sparrow,  invites  the  latter  in  its  own  language  to  depart  ; com- 
plaints, however,  appearing  useless,  it  goes  off  to  invoke  the  aid  of 
its  fellows.  Soon  after,  the  swallows,  in  goodly  numbers,  make  a 
demonstration  before  the  usurping  sparrow,  all  flying  together  before 
the  occupied  nest.  This  simple  device  also  proving  fruitless,  they 
fly  off,  only  to  return  laden  with  clay,  with  which  they  proceed  to 
confine  the  careless  and  haughty  invader  in  the  nest  so  insolently 
appropriated.  It  is  evident  that  the  swallows  must  communicate 
emotions  and  images— certainly  emotions  rather  than  notions. 
Similar  examples  in  the  life  and  customs  of  animals  are  by  no  means 
infrequent.  If,  however,  these  have  a bearing  upon  the  compre- 
hension of  the  emotional  side  of  language,  it  is  yet  more  important 
to  us  to  consider  language  especially  as  the  expression  of  thought. 

The  reader  is  already  acquainted  with  the  present  extent  of  our 
knowledge  concerning  the  perceptions  and  the  areas  where  the 


128 


PSYCHIATRY 


images  are  formed  and  preserved.  In  this  connection  I have  chosen 
the  visual  images  and  the  visual  zone,  in  the  first  place  because  the 
visual  area,  as  we  have  said,  is  best  known,  and  in  the  second  place 
because  the  psychic  content  of  our  language  is  in  great  part  visual, 
or  derived  from  visual  images.  All  the  auditory  images  which  are 
not  words  (sounds,  musical  tones,  rumblings,  etc.)  are  emotional 
rather  than  intellectual  ; to  become  such  it  is  necessary  that  they 
be  associated  with  a visual  and  tactile  image.  The  song  of  the 
nightingale  or  the  sound  of  the  violin  is  intellectual  only  when  we 
possess  the  visual  and  tactile  image  (as  happens  in  the  blind)  of 
the  nightingale  and  the  violin,  and  these  form  psychic  compounds 
by  combination  with  other  psychic  or  simply  sensory  products. 
While  the  visual  and,  to  a slight  extent,  also  the  tactile  zone  provide 
us  with  immense  objective  material  capable  of  being  transformed 
into  language,  the  auditory  zone  furnishes  us  only  with  emotional 
material,  with  which  Nature  hurts  or  pleases  our  senses,  and  with 
linguistic  material,  which  has  been  accumulating  in  proportion  as 
the  emotions  and  images  are  themselves  translated  into  spoken 
language. 

We  arrive  at  the  conclusion  that  the  whole  brain  concurs  in  the 
formation  of  thought,  inasmuch  as  this  is  only  the  physiological 
fusion  of  simpler  images,  which  in  their  turn  are  furnished  by 
different  orders  of  neurones  scattered  or  grouped  together  in  the 
different  regions  of  the  cerebrum.  The  ideas  evolve  themselves 
and  become  more  complex  by  association  with  and  assimilation  of 
new  factors,  while  the  anatomical  field,  whence  they  draw  their 
formative  elements,  becomes  progressively  more  extended. 

Thought  arises  in  the  field  of  the  concrete  images  on  the  one 
part  (sensory  zone)  and  in  the  field  of  the  abstract  ideas  on  the 
other  (frontal  lobes  ; see  afterwards),  and  therefore  we  may  con- 
clude on  good  grounds,  contrary  to  several  other  authorities,  that 
there  exists  an  intellectual  field  distinct  from  that  of  speech,  con- 
sidered per  se,  and  that  this  can  be  disturbed,  not  only  when  the 
organs  of  its  direct  formation  are  injured,  but,  in  addition,  when 
there  is  injury  of  the  mechanisms  formative  of  the  concrete  images 
and  of  the  abstract  ideas,  or  when  there  are  interrupted  either 
the  paths  which  establish  connections  between  the  different  parts 
whence  there  results  a complex  idea,  or  the  paths  between  the 
ideative  representations  and  the  kinaesthetic  fields  whence  they 
become  expressive. 

We  may  imagine  we  have  satisfactorily  delimited  the  intellectual 
field  connected  with  the  function  of  language,  but  such  is  not  the 
case,  except  so  far  as  is  requisite  for  a schematic  exposition.  There 
are  as  many  intellectual  centres  as  there  are  series  of  empirical 
images  bound  to  words.  The  words  ‘ pen,’  ‘ ink-bottle,’  have  their 
respective  empirical  images  in  the  visual  zone  ; the  words  ‘ blowing,’ 

‘ rustling,’  ‘ whistling,’  have  their  predominant  sensory  equivalents 


physiologS^  of  the  language 


129 


in  the  auditory  centre  ; the  words  ‘ rough,’  ‘ polished,’  ‘ hectogram,’ 
have  their  respective  images  in  the  tactile,  visual,  and  muscular 
centres  ; the  words  ‘ school,’  ‘ war,’  ‘ humanity,’  have  their  intel- 
lectual equivalents  in  the  frontal  lobes. 

No  matter  what  the  origin  of  images  which  become  suppressed, 
there  results  therefrom  an  amnesic  disturbance  of  speech,  and  there 
is  every  reason  to  believe  that  there  may  be  as  many  forms  of 
amnesia  as  there  are  sensory  or  perceptive  areas  in  the  cerebral 
cortex.  Accordingly,  if  through  destruction  of  a perceptive  zone, 
or  of  that  of  the  concepts,  certain  categories  of  images  disappear, 
and  if  the  image  lost  is  not  substituted  by  another  allied  to  the  same 
word,  this  will  not  be  recoverable.  For  example,  if  at  night  we 
hear  the  tolling  of  a bell,  the  word  ‘ bell  ’ will  be  revived  by  the 
auditory  image.  In  the  daytime  the  same  word  comes  to  the  lips 
if  we  happen  to  pass  near  a belfry  and  our  gaze  fall  upon  the  bell. 
One  of  these  images  is  alone  sufficient  to  arouse  the  auditory  or  the 
kinaesthetic  image  of  the  word  and  to  permit  of  the  pronunciation 
of  the  word  ‘ bell.’  Smell  and  touch  enable  us,  in  the  dark,  to 
recognise  the  flower  and  pronounce  the  word  ‘ rose,’  and  the  same 
thing  can  happen  on  beholding  it  from  a distance.  Cases  occur  in 
which  an  extensive  cerebral  lesion  destroys  one  or  even  two  of  the 
sources  of  the  images  referable  to  the  same  object,  yet  the  word 
persists,  because  only  one  image  is  necessary  in  order  to  arouse  it, 
although  this  occurs  with  greater  difficulty. 

In  this  way  we  have  an  explanation  of  the  formative  disturb- 
ances in  the  field  of  the  images  or  in  that  of  the  concepts, 
constituting  a first  class  of  amnesias  of  speech,  which  I shall  desig- 
nate intellectual,  and  further  distinguish  into  imaginative  and 
conceptive. 

Does  there  exist  a centre  of  intelligence  distinct  from  that  of  speech  ? 
Among  those  authorities  seriously  occupied  in  the  study  of  language 
a great  difference  of  opinion  prevails  concerning  the  existence  of 
at  least  one,  but  mayhap  of  several  intellectual  centres  distinct  from 
those  of  the  images  of  words.  Broadbent  especially,  since  1872, 
has  treated  the  subject  with  the  greatest  width  of  observation  and 
with  most  appreciation  of  the  facts.  He  then  advanced  the  view 
which  to-day  we  can  still  hold,  founding  our  modern  observations 
upon  anatomical  and  physiological  knowledge  then  non-existent, 
that  there  are  rudimentary  perceptive  states  which  furnish  simple 
attributes  of  things,  wherefrom  we  pass  to  elaboration  of  a higher 
grade  resulting  from  combinations  of  perceptions  from  which  we 
form  the  conception  or  the  general  idea  of  an  object.  The  formation 
of  the  general  idea  of  an  object  is  accompanied  by  the  association 
of  a name  expressive  of  that  object.  The  high  elaboration,  the 
fusion  of  the  various  perceptions,  does  not  take  place  through 
radiation  from  one  centre  of  perception  to  all  the  other  correlatives, 
as  Bastian  maintained  some  years  previously,  but  by  convergence 

9 


130 


PSYCHIATRY 


of  the  products  of  the  various  perceptive  centres  upon  a common 
intermediate  cell  area. 

This  intermediate  cell  area,  wrote  Broadbent,  forms  a kind  of 
supreme  centre  composed  of  convolutions  which  do  not  receive 
fibres  of  projection.  More  than  twenty  years  previously,  then, 
Broadbent  had  put  forward  the  question  which  Flechzig,  relying 
upon  anatomical  research,  believed  he  had  fixed  upon  a sounder 
basis.  Where  we  cannot  agree  with  Broadbent  is  in  his  affirmation 
that  the  centre  of  concepts  would  be  the  centre  for  names.  We 
shall  see  later  on  that  this  doctrine  is  untenable. 

All  those  others  who,  after  Broadbent,  have  spoken  of  a distinct 
intellectual  centre,  such  as  Kussmaul,  Charcot,  Bernard,  Ballet, 
Lichtheim,  and  several  others,  with  the  exception  of  Grasset,  and 
latterly  of  Pitres,  who  handles  the  subject  more  clearly,  have  kept 
themselves  in  a field  of  the  abstract,  and  have  reproduced  their 
abstractions  in  diagrams  which  have  not  had  psychological  or 
anatomical  explanation  in  any  individual  case. 

The  localizing  doctrine,  as  above  described,  does  not  find  favour 
with  many  other  no  less  worthy  writers.  Among  these  are  De  Watte- 
ville,  Ross,  Allen,  Starr,  Wyllie,  and  others,  who  do  not  admit  the 
existence  of  separate  centres  for  the  conceptions.  Bastian,  in  par- 
ticular, has  written  in  a recent  work  : ‘ I am  unable  to  find  from 
clinical  data  any  clear  evidence  proving  the  existence  of  defect  of 
speech,  which  can  be  explained  only  upon  the  supposition  that  there 
exists  a lesion  in  the  centre  of  the  conceptions  or  in  the  course  of 
its  afferent  or  efferent  fibres.  ...  It  seems  even  probable  that 
there  is  no  line  of  demarcation  between  the  various  sensory  areas 
and  the  conjoined  areas  called  associative  by  Flechsig,  and  that  the 
sensory  areas,  together  with  the  conjoined,  are  accustomed  to 
functionate  more  or  less  simultaneously.’ 

The  existence  of  centres  for  the  images  of  objects  and  their 
abstract  conception,  distinct  from  the  sensory  centres  for  their 
denomination,  arises,  in  my  opinion,  from  this,  that  the  verbal 
image  is,  on  the  whole,  distinct  from  the  image  of  the  object  itself 
to  which  it  refers.  We  very  frequently  recognise  objects  without 
being  able  to  name  them,  and  as  frequently  do  we  recall  the  name 
of  an  object  whose  image  is  not  reawakened,  or  which  appears  more 
slowly  in  the  memory.  Clinical  observations  show  likewise  how, 
by  certain  lesions,  one  can  recognise  an  object  with  the  sight  without 
being  able  to  give  it  its  name,  and  how,  from  certain  others,  one  can 
repeat  the  name  of  an  object  without  being  able  to  reawaken  the 
image  of  the  same.  All  this  shows  with  sufficient  evidence  that 
the  two  images  are  distinct  and  furnished  by  two  separate  centres 
associated  with  each  other.  Further,  the  story  of  the  development 
of  thought  and  of  speech  furnishes  fresh  proof  of  the  value  of  the 
theory  I maintain.  An  infant  has  already  a significant  possession 
of  images  of  persons  and  objects  before  the  formation  of  the  corre- 


PHYSIOLOGY  OF  THE  LANGUAGE 


131 

spending  verbal  images.  Again,  animals,  which  do  not  speak, 
recognise  a number  of  things  and  persons. 

Rather  more  difficult  is  the  solution  of  the  problem  from  the 
side  of  the  abstract  conceptions,  which  very  naturally  cannot  be 
reawakened  unless  by  means  of  the  sensible  form  of  the  respective 
word  with  which  they  are  strictly  allied  and  well-nigh  fused.  It  is 
certain  that  we  may  be  able  to  reproduce  the  image  of  a man  without 
need  of  the  word  ‘ man,’  but  we  will  not  be  able  in  any  way  to  form 
the  conception  of  humanity  without  the  word  ‘ humanity.’  The 
very  most  we  can  do  is  to  figure  humanity  to  ourselves  by  dividing 
the  conception  into  its  concrete  images  of  different  men  with  varying 
human  attributes,  in  which  case  it  ceases  to  be  an  abstract  concep- 
tion. The  coalescence  of  the  word  with  the  abstract  conception, 
and  the  impossibility  of  separating  them,  do  not  warrant  us  in 
denying  that  they  are  formed  in  different  areas.  Leaving  aside, 
too,  aU  the  clinical  observations,  the  experiments  done  by  me  in 
the  inquiry  into  the  functions  of  the  frontal  lobes,  and  the  legitimate 
conclusions  at  which  I have  arrived,  we  can  obtain  from  another 
source  good  arguments  for  considering  as  distinct  the  two  elements, 
mechanism  and  site,  and  these  are  furnished  by  inquiry  into  the 
state  of  language  and  intelligence  at  one  moment  of  their  respective 
evolution.  An  idiot,  e.g.,  can  learn  to  pronounce  the  word  ‘ hu- 
manity ’ without  having  the  conception  of  humanity.  In  the  same 
way,  the  child  calls  all  the  men  it  sees  ‘ papa,’  because  it  has  not  yet 
the  abstract  conception  of  father,  but  has  only  the  concrete  image 
of  the  man  who  most  frequently  fondles  it.  If,  then,  the  word  can 
be  learned  and  pronounced  completely  void  of  conceptive  signifi- 
cance, as  in  the  case  of  infants  and  idiots,  and  if  it  be  true  that  even 
the  dements,  when  their  intelligence  is  resolved  into  its  elements, 
can  pronounce  many  words  deprived  of  their  signification  and 
devoid  of  any  conceptive  content  whatsoever,  inasmuch  as  the 
concepts  themselves  are  resolved  into  their  imaginative  elements, 
many  of  which  have  been  lost  with  the  destruction  of  the  mind,  one 
can  only  conclude  that  the  words  which  clothe  the  conceptions 
have  a seat  of  distinct  formation,  and  that,  whilst  in  one  case  the 
conceptions  may  disappear  and  the  words  remain,  in  another  the 
latter  may  disappear  and  the  former  remain  in  a state  of  latency. 
The  sole  difference  lies  in  this,  that  there  will  always  be  wanting 
sensible  proof  of  the  existence  of  the  conception  on  destruction  of 
the  centre  of  the  images  of  the  respective  words,  because  in  no 
manner  are  these  conceptions  reproducible  unless  by  means  of  a 
concrete  and  simple  form,  which  is  that  of  spoken  and  written 
language. 

We  need  no  expenditure  of  words  to  show  that  the  conclusion 
drawn  from  what  we  have  so  far  set  forth  is  that  all  the  sensory 
areas  of  the  cerebral  mantle,  besides  the  conceptive,  to  which  we  shall 
turn  our  attention  later  on,  ought  to  be  regarded  as  the  intellectual 

9—2 


PSYCHIATRY 


132 

field  of  language,  inasmuch  as  they  furnish  concrete  images  and 
conceptions  which  form  the  substance  of  speech,  and  that,  in  con- 
sequence, there  are  many  forms  of  amnesic  aphasia,  seeing  that  if 
it  is  competent  to  apply  the  word  amnesic  to  that  form  of  aphasia 
in  which  the  word  cannot  be  recalled,  when  there  is  wanting  or  cannot 
be  aroused  the  verbal  image  which  determines  its  articulation,  then 
in  like  manner  the  same  word  will  not  be  capable  of  being  aroused 
and  pronounced  when  there  is  wanting  the  image  of  the  object, 
which  ought  to  reawaken  that  of  the  respective  word.  In  each  case 
the  phenomenon  can  assume  the  same  external  form,  although  the 
origin  is  different  ; and  if  we  add  still  a third,  when  by  the  inter- 
ruption of  the  paths  of  association  between  the  image  of  the  object 
and  that  of  the  word  the  former  cannot  reawaken  the  latter,  the 

effect  is  identical.  _ , i r . 

A form  of  amnesic  conceptive  aphasia  is  not  so  capable  of  demon- 
stration, because  in  the  cases  where  the  concepts  are  defective 
the  words  can  be  pronounced  if  rearoused  by  simple  concrete 
images,  and  we  shall  find  ourselves  confronted  by  examples  of  more 
or  less  serious  intellectual  disorders  which  we  cannot  examine  in 
detail  in  this  part  of  the  work.  When,  on  the  other  hand,  the 
words  which  clothe  the  concepts  are  defective,  the  latter  cannot  be 
utilized  in  the  psychic  manifestations  of  the  sufferer,  because,  as  we 
shall  presently  see,  according  to  the  part  they  play  in  the  mechanism 
of  psychic  life,  so  they  are  clothed  in  a sensible  form  the  word.  It 
is  quite  apparent,  then,  that  the  old  conception  of  amnesic  aphasia 
is  much  enlarged,  and  applies  to  all  the  partial  and  total  failures  of 
words  or  of  the  whole  language,  according  as  it  depends  either  on 
a lesion  of  the  verbal  images  or  a lesion  of  the  centres  of  the  images 
of  the  objects,  and  it  is  easy  to  deduce  that  one  cannot  assign  a 
specific  site  to  amnesic  aphasia.  All  those  who  are  anxious  to 
demonstrate  the  contrary  either  make  reference  to  the  most  classic 
of  the  forms  of  verbal  amnesia  in  the  sense  of  Charcot,  viz.,  the 
acoustic,  or  have  fallen  into  the  error  of  utilizing,  without  much 
criticism,  the  doctrines  of  Flechsig.  There  cannot  be  a fixed  and 
exclusive  seat  of  amnesic  aphasia,  but  just  as  many  seats  as  there 

are  various  forms  of  it.  . 1 

Furthermore,  it  must  be  noted  that,  as  in  different  individuals 
the  various  cerebral  provinces  are  not  equally  cultivated  and  fertile 

the  temporal  province  being  more  prolific  in  some,  the  parietal 

in  others — the  natural  result  is  that  lesions  of  the  same  extent  and 
depth,  granted  that  this  be  possible,  produce  effects  different  in 
proportion  to  the  loss  of  the  intellectual  or  verbal  capital. 

To  this  incomplete  conception  of  amnesic  aphasia  Pitres  also  ha^j 
given  expression,  and  he  even  admits  a psychic  field  which,  according 
to  Sollier,  would  be  that  in  which  the  images  are  deposited,  and 
whence  issues  the  evocative  impulse.  Amnesic  aphasia  would  be 
produced  by  interruptions  of  the  fibres  which  unite  the  centies  0 


PHYSIOLOGY  OF  THE  LANGUAGE 


133 


language  with  the  centre  of  ideation  (it  is  more  correct  to  speak  of 
the  field  of  ideation).  In  other  words,  amnesic  aphasia  would  be 
one  of  the  forms  of  subcortical  aphasia  ; in  fact,  one  might  even 
term  it  aphasia  of  association.  In  such  a case  the  repetition  of  the 
word  pronounced  by  others,  and  understood  and  recognised  by  the 
patient,  could  occur  by  collateral  paths,  and  especially  by  the  com- 
missural paths  of  the  right  hemisphere.  It  is  quite  evident,  however, 
that  this  is  only  one  form  of  amnesic  aphasia. 

Clinical  observation,  moreover,  compels  us  to  admit  a form  of 
asthenic  amnesic  aphasia,  which  can  be  observed  in  some  cases  of 
neurasthenia  and  incipient  degenerative  processes  of  the  cerebral 
cortex.  There  are  individuals  who  possess  ideas,  and  preserve,  within 
certain  limits,  the  power  of  representing  what  they  wish  to  express, 
but  who  fail  to  find  the  word.  This  asthenic  form  of  amnesic  aphasia 
consists  essentially  in  this,  that  the  sensory  images  of  the  word,  the 
auditory  and  the  visual,  which  are  furnished  essentially  by  a series 
of  sensory  factors  that  ought  to  concur  in  the  formation  at  first  of 
the  image  of  the  object,  and  thereafter  the  verbal  images,  are  so 
feeble  that  they  do  not  succeed  in  combining  and  presenting  them- 
selves in  an  efficient  manner.  For  example,  the  conception  of  a 
key  results  from  a series  of  sensory  factors — the  form  of  the  key,  the 
weight  of  the  key,  the  conception  of  iron  in  the  key,  and  then  the 
noise  of  the  key  in  shutting  the  door,  concerning  which  Dante 
speaks  in  these  words  to  Count  Ugolini  : ‘ I felt  the  locking  of  the 
door  at  the  foot  of  the  horrible  tower  ’ — that  is,  as  the  result  of 
the  noise,  he  had  presented  to  him  first  the  image  of  the  key  in  use, 
and  then  the  thermic  sense  of  the  key  when  taken  in  the  hand,  but 
more  especially  the  muscular  sense  of  the  act  of  turning  the  key 
in  the  lock.  We  have  here,  then,  a series  of  images  which  are 
related  to  the  image  of  the  key,  and  all  should  concur  in  forming 
the  abstract  conception  and  the  sensory  image  of  the  word.  If, 
however,  those  images  are  so  feeble  that  by  arousing  one  the 
others  are  not  evoked,  because  the  nerve  current  does  not  reach  all 
the  neurones  in  which  they  are  formed,  the  representation  of  the 
verbal  image  of  the  key  cannot  take  place.  In  these  cases,  if  the 
images  make  themselves  felt  more  strongly  through  a reawakening 
by  actual  stimuli  (as  when  the  key  is  given  into  the  hand  of  the 
aphasic),  the  corresponding  word  is  rearoused  and  pronounced. 

The  study  of  language  has  rather  a wider  scope  than  has  hitherto 
been  accorded  to  it,  even  by  some  very  recent  authors.  The 
amnesias  of  which  we  have  so  far  spoken  cannot  be  separated 
from  the  aphasias  in  this  respect,  that  if  aphasia  is  motor  in  its 
aspect,  consisting  in  the  inability  to  reproduce  the  kinaesthetic 
images  of  spoken  language — whence  the  impossibility  of  expressing 
thought  in  spoken  form,  which  in  its  essence  is  nothing  else  than 
an  amnesia  of  the  kinaesthetic  images — then  amnesia  is  the  in- 
capacity to  reproduce  the  auditory  or  visual  images  of  the  words, 


134 


PSYCHIATRY 


according  to  the  feebleness,  paralysis,  or  total  destruction  of  the 
corresponding  formative  and  recording  centres  of  those  images. 
Having  admitted  the  fact  of  the  existence  of  distinct  centres  com- 
posed of  specialized  neurones  where  are  formed  and  registered  the 
images  of  objects  and  the  visual,  auditory,  and  kinaesthetic  images 
of  words,  one  cannot  but  agree  that  a paretic  condition  (not  destruc- 
tion) of  the  various  centres  must  consequently  bring  about  an 
inability  to  reproduce  a more  or  less  considerable  number  of  the 
respective  images ; hence  the  diverse  forms  of  amnesia  and  of  amnesic 
aphasia  which  we  can  distinguish  as  visual,  auditory,  and  tactile. 

In  my  opinion,  however,  the  study  in  question  can  only  advance 
on  the  exclusive  basis  of  clinical  and  anatomico-pathological  facts. 
Thus,  it  is  upon  the  ground  of  observation  of  the  visual  or  auditory 
faculty  of  individuals  who  remember  less  easily  than  formerly  the 
verbal,  visual,  or  auditory  images  of  speech  that  I found  the  exist- 
ence of  particular  forms  of  amnesic  aphasia  through  weakness 
(degenerative  processes)  of  individual  centres  for  the  verbal  images. 
Such  individuals  have  lost  more  or  less  of  their  faculty  of  repro- 
ducing the  images  of  words,  and  have  a correspondingly  greater 
or  less  facility  of  speech.  In  other  words,  their  speech  and  their 
writing  also  have  become  poorer,  harder,  and  slower.  This  con- 
dition of  things  is  brought  about  by  two  orders  of  facts — either  it 
is  due  to  a cortical  or  subcortical  destructive  focus,  which,  by  vicinity 
and  all  those  nutritive  disturbances  which  a destructive  focus 
induces  in  the  surrounding  cerebral  zone,  paralyzes  the  centre  of 
verbal  images,  or  there  exists  a neurasthenic  condition  of  one  or 
both  centres. 

I have  had  an  opportunity  of  examining  several  individuals  who, 
formerly  ready  and  happy  in  their  reproduction  of  all  the  words 
learned  during  the  period  of  their  education  at  a certain  period  in 
their  lives — frequently  not  advanced — lose  that  property  which 
rendered  them  as  speakers  ready,  acute,  and  felicitous  in  adapting 
to  each  thought  the  adequate  expression,  to  each  object  the  proper 
name.  Individuals  who  have  read  a great  deal,  and  who,  after 
having  brought  themselves  to  a high  grade  of  education  and  potency, 
have  excessively  exhausted  the  visual  centre  of  speech,  where  they 
had  accumulated  a wealth  of  images  for  the  service  of  the  whole 
intellectual  and  linguistic  mechanism,  observe  a difficulty  and  some- 
times an  inability  to  reproduce  with  the  same  readiness  as  formerly 
those  images  which  render  language  richer  and  more  ornate. 

As  much  may  be  said  with  regard  to  the  phonic  images  in  the 
case  of  those  who  have  been  accustomed  to  listen.  If  these  forms 
of  verbal  amnesia  have  so  far  eluded  clinical  analysis,  and  are  con- 
sidered under  the  general  conception  of  cerebral  neurasthenia,  no 
one  who  henceforth  will  devote  proper  attention  to  the  subject  will, 
in  my  opinion,  be  able  to  dispute  that  these  forms  of  neurasthenia, 
so  far  from  being  generally  dependent  on  the  entire  cerebral  function. 


INTRINSIC  FACTORS  OF  SPEECH 


135 


are  due  to  paralysis  of  the  most  delicate  centres,  latest  in  cerebral 
development,  and  yielding  the  most  complex  product  of  life,  which 
is  language.  Further,  the  disturbance  resulting  from  it  is  precisely 
an  amnesia,  which  differs  in  no  respect,  as  regards  the  mechanism 
and  essential  manifestations,  from  the  amnesic  aphasia  induced  by 
destructive  foci  in  proximity  to  the  auditory  and  visual  centres  of 
speech. 

From  all  we  have  said,  the  legitimate  conclusion  drawn  is  that 
amnesic  aphasia  cannot  have  one  seat  only,  but  a number  corre- 
sponding to  the  various  forms  of  it  and  to  the  relations  between 
the  verbal  sensory  areas  and  the  other  cerebral  regions.  If  we  are 
dealing  with  individuals  with  a trained  auditory  faculty,  a lesion 
inducing  a state  of  arrest  or  of  paresis  of  the  first  temporal  convo- 
lution causes  an  amnesic  aphasia  (Charcot)  ; if,  on  the  other  hand, 
with  persons  educated  to  speak  by  preference  from  the  visual 
images,  which  by  prolonged  exercise  have  acquired  a capacity  of 
easy  and  ready  reproduction  and  a greater  vividness  than  the 
auditory  images,  a paralysis  affecting  the  visual  centre  will  suppress 
the  visual  image. 

The  commissural  bundle  between  the  auditory  and  the  visual 
centre  of  speech  may  be  interrupted,  and  in  this  case  (granted  the 
relations  of  functional  dependence  of  the  one  centre  upon  the  other) 
the  two  centres  are  found  in  a condition  of  paresis  or  of  arrest,  and 
although  both  centres  may  be  themselves  unimpaired,  they  will  no 
longer  be  able  to  furnish  all  the  images  requisite  for  articulate  speech. 

In  the  same  way,  if  there  be  an  interruption  of  the  path  between 
the  conceptive  field  and  the  auditory  and  visual  sensory  areas,  as 
well  as  the  kinaesthetic,  there  will  be  equally  a defect  of  speech, 
because  the  ideas,  now  less  vivid  and  more  difficult  to  recall  by 
reason  of  the  broken  relations  resulting  from  failure  of  some  com- 
ponents, are  no  longer  able  to  reawaken  the  auditory,  visual,  or 
kinaesthetic  images  which  are  necessary  to  bring  into  play  the  motor 
centre  of  speech.  We  will  resume  this  question,  however,  when 
we  take  up  the  disturbances  of  memory. 

Intrinsic  Factors  of  Speech. — So  far  we  have  occupied  our- 
selves with  the  intellectual  factors  and  their  fundamental  impor- 
tance as  the  substance  of  speech,  and  with  the  forms  of  aphasia 
(amnesic)  which  arise  either  from  a suppression  of  some  of  the 
intellectual  components  of  language  or  from  some  impediment  in 
their  interrelations.  Let  us  now  turn  our  attention  to  the  intrinsic 
constituent  elements  of  speech  considered  per  se,  and  which,  in 
order  to  distinguish  them  from  the  above,  I term  neuro-psychic 
factors. 

In  the  modem  individual  who  can  read  and  write  these  latter 
factors  are  four  in  number  : the  acoustic  and  the  visual  images  of 
speech  (impressive  components),  the  kinaesthetic  articulatory  and 
the  kinaesthetic  graphic  images  (expressive  components) 


136 


PSYCHIATRY 


Which  of  all  these  neuro-psychic  components  of  language  is  the 
most  essential  in  the  mechanism  of  speech  ? On  this  point  all 
authorities  are  not  in  agreement.  While  Charcot  and  the  writer 
have  recognised  the  greatest  formative  and  regulative  factor  of 
speech  in  the  acoustic  images,  Strieker,  Bastian  and  a few  others 
accord  the  greatest  value  to  the  kinsesthetic  articulatory  image. 

Strieker,  who  has  given  much  attention  to  the  psychology  of 
language,  has  arrived  at  conclusions  not  quite  tenable,  owing  to 
the  fact  that  he  has  considered  the  mechanism  of  language  in  a too 
exclusive  and  one-sided  manner.  According  to  him,  speech  is  the 
outward  manifestation  of  the  word  itself  represented  as  a motor 
image.  He  argues  that  when  we  say  ‘B’  inwardly  to  ourselves, 
when  all  around  is  quiet,  we  feel  something  at  our  lips  and  tongue 
a sensation  of  contraction,  of  movement,  which  is  nothing  else  than 
the  memory  of  the  movement  executed  by  us  at  other  times  in  pro- 
nouncing the  sound  of  the  letter  B,  which  leaves  a mnemonic 
image,  reproduced  when  we  have  to  pronounce  a like  sound.  The 
problem  has  not  been  set  forth  in  all  its  bearing  by  Strieker,  because, 
whilst  setting  too  much  value  upon  the  motor  or  senso-motor  image, 
he  has  underrated  that  of  the  other  images  of  speech.  When  we 
think  of  a word — s-.g.,  ‘ love  ’ — there  is  not  reawakened,  according 
to  the  doctrine  of  Strieker,  the  phonic  or  visual  image— he.,  the 
recollection  of  the  word  heard  or  read  at  a former  time— but  the 
sensation  of  the  innervation  transmitted  to  the  tongue,  lips,  and 
the  larynx,  as  if  we  pronounced  that  word  in  a low  voice.  What 
we  really  notice  is  the  same  impulse,  which  is  irradiated  to  the  peri- 
pheral organs  of  language,  but  differing  in  intensity  ; and  some- 
times, in  thinking  of  the  words,  we  can,  by  observing  attentively, 
notice  slight  corresponding  vibrations  of  the  lips,  the  tongue,  and  the 
larynx. 

Thus  Strieker  comes  to  the  conclusion  that  articulate  speech  is 
entirely  dependent  upon  the  mnemonic  reproduction  of  the  motor 
image  (kinsesthetic  according  to  Bastian). 

One  cannot  disregard  the  fact  that  the  subjective  method 
renders  great  service  in  the  study  of  language  ; but^  one  cannot 
exaggerate  its  value  without  running  the  risk  of  restricting  one  s self 
to  an  unnaturally  limited  range  of  observation.  When  we  turn 
our  attention  and  fix  it  too  long  on  one  sensation,  one  image,  01 
one  idea,  this  makes  itself  strongly  felt,  and  by  the  same  action  all 
the  others  diminish  in  proportion.*  Thus  it  is  that  if  we  think  of 
the  kinsesthetic  impressions  which  we  receive  in  the  act  of  pro- 
nouncing B,  we  perceive  only  these,  or  at  least  the  great  predomi- 
nance of  these  over  the  others.  WT  feel  something  which  recoids 
the  sensation  produced  by  the  organs  of  speech  in  the  act  of  pro- 
nouncing the  letter  B ; but  that  is  not  all,  for  the  very  simple 
reason  that  the  verbal  image  is  not  the  representation  of  one  simple 
sensation,  but  the  reproduction  of  many  sensations  closely  associ- 


INTRINSIC  FACTORS  OF  SPEECH 


137 


ated.  A simple  representation  can  be  received  only  abstractly. 
In  fact,  the  moment  I think  of  the  letter  B,  there  is  reawakened 
in  my  mind  the  acoustic  image,  the  visual  image,  and  that  of  the 
movements  of  the  lips  and  tongue,  by  virtue  of  which  I pronounce 
the  sound  of  that  letter.  Of  this  complexity  of  sensations  there 
is  reawakened  in  preference,  in  different  individuals,  now  the 
kinaesthetic,  now  the  auditory,  or,  again,  the  visual,  according  to 
the  preponderating  development  and  education  of  the  senses  in 
each,  and  according  as  the  attention  is  fixed  more  intensely  on  one 
particular  image  than  on  the  others.  In  my  own  case,  in  fact,  I 
feel  something  at  my  lips,  but  have  also  the  reawakening  of  the 
acoustic  image  of  the  sound  of  the  letter  or  syllable  and  the  visual 
image  of  the  letter  itself.  Of  these,  however,  I notice  the  muscular 
and  tactile  sensations  less  than  the  others. 

Ideation  consists  in  a co-ordination  of  sensory  representations. 
The  idea  which  the  illiterate  have  of  B is  quite  different  from 
that  of  one  who  can  read  and  write. 

What  we  say  of  letters  holds  good  also  of  words,  seeing  that 
words  are  only  a collection  of  syllables  and  of  letters.  Let  us  take, 
e.g.,  the  word  ‘ school.’  According  to  Strieker,  it  would  be  the  group 
of  kinaesthetic  images  corresponding  to  the  syllabic  motor  images 
that  would  determine  the  articulate  sound.  Accordingly,  this 
would  represent  merely  the  reflex  reproduction  of  a series  of  senso- 
muscular  images.  But  it  is  clear  that  in  wishing  to  reproduce,  in 
imagination,  the  word  ‘ school,’  we  reawaken  not  only  the  senso- 
muscular,  but  also  the  acoustic  and  visual  image  of  that  word,  and, 
further,  an  infinity  of  verbal  images  and  representations  of  rooms, 
gatherings,  persons,  notions,  etc.,  closely  associated  with  the 
emotions  formerly  experienced  in  childhood.  Every  one  of  these 
images  evokes  by  itself,  according  to  associative  law,  the  word 
‘ school  ’ by  reawakening  the  auditory  and  visual  images  of  the  word 
itself.  The  kinaesthetic  is  the  least  conscious,  and  that  which  has 
the  least  power  of  reproducing  the  word,  although  it  may  represent 
the  ultimate  and  necessary  instrument  without  which  the  utterance 
would  not  be  possible.  The  word,  then,  is  more  than  the  mere 
reproduction  of  the  muscular  image,  which  has  weaker  reproduc- 
tive power  in  comparison  with  the  others,  albeit  it  is  closely  allied 
with  the  visual  and  the  acoustic  images,  which  are  simultaneously 
rearoused,  and,  I would  say,  almost  fused  with  it. 

The  analysis  of  speech,  which  appears  to  be  a functional  unit, 
and  is  in  reality  a product  of  the  coalescence  of  an  immense  number 
of  functional  units,  which  in  their  turn  are  the  product  of  as  true 
anatomical  units  scattered  throughout  the  cortex  of  the  brain, 
should  lead  us  to  suppose  that  all  these  anatomical  and  cortical 
units,  and  the  groups  of  these,  which  work  towards  the  formation 
of  language,  must  be  closely  correlated  by  paths  of  communication 
and  association.  It  is  very  natural,  then,  that  interruption  of 


138 


PSYCHIATRY 


these  paths,  by  breaking  the  communication  between  two  or  more 
groups  of  cortical  units,  must  impede  the  formation  of  the  complex 
product  resulting  directly  from  the  combination  of  the  elementary 
functional  products  of  two  or  more  groups,  and  give  rise  to  simpler 
or  altogether  abnormal  products.  Thus  it  has  come  about,  especi- 
ally in  these  latter  years,  as  the  result  of  a work  of  delicate  analysis, 
that  the  great  importance  of  the  paths  of  association  has  been 
brought  into  evidence,  and  another  group  of  physiological  factors 
of  language  has  been  distinguished,  with  a corresponding  group  of 
clinical  figures  differing  from  each  other.  I refer  to  the  associative 
factors  and  the  respective  subcortical  aphasic  disturbances. 

But  such  a work  of  association,  whence  results  a product  so 
complex  as  speech,  is  subject  to  fundamental  laws,  among  which 
the  most  evident  are  : (i)  The  commanding  preponderance  of  one 
component  of  language  over  all  the  others  ; and  (2)  the  individual 
varieties. 

The  preponderance  of  one  component  over  the  others,  or,  let 
us  say,  the  government  of  the  whole  mechanism,  is  held  by  that 
factor  which  has  been  fundamentally  the  first  in  the  evolution  of 
language  in  the  species,  and  is  the  first  always  in  the  evolution  of 
language  in  the  individual. 

One  can  admit,  with  much  probability,  the  hypothesis  that  the 
phonic  or  acoustic  centre  of  articulate  sounds  is  the  first  to  be 
differentiated  for  the  specific  function  of  language  in  the  cortical 
auditory  area,  and  to  me  it  seems  evident  that  even  in  the  infant 
the  articulate  sounds  first  emitted  are  only  a fragment  of  more 
complex  sounds  which  have  already  specialized  some  cortical  units 
of  the  auditory  centre.  Everyone  knows  that  a considerable  time 
elapses  before  the  infant  is  able  to  articulate  a word  whose  phonic 
image  has  already  been  registered  for  a long  time.  There  are  set 
up  by  this  means,  not  only  relations  between  the  phonic  centre 
and  the  centre  of  articulation  of  the  word,  but  likewise  a kind  of 
regulative  influence  exercised  by  the  former  upon  the  latter,  which 
displays  the  nervous  impulses  in  the  form  of  articulate  sounds,  just 
as  they  have  been  formed  under  the  projection  of  the  acoustic 
image  of  the  word.  If  this  last  should  be  awanting,  or  if,  by  in- 
terruption of  the  associative  paths,  the  respective  nervous  impulses 
cannot  reach  the  other  group  of  cortical  units  where  are  generated 
and  whence  are  emitted  the  kinaesthetic  impulses  that  call  into 
play  the  motor  mechanism  of  speech,  this  will  fail  completely,  or 
will  be  entirely  changed  and  rendered  unintelligible. 

The  phonic  image  exercises,  likewise,  a regulative  power  over 
the  visual  image  of  speech.  The  infant  learns  to  read  only  when 
the  phono-motor  part  of  language  is  developed,  and  also  functionally 
perfected.  Visual  images  of  letters,  syllables,  and  words,  can  only 
be  formed  by  moulding  themselves  to  the  phonic  images,  and  also 
perhaps  to  tiie  kinaesthetic.  They  will  be  re-evoked,  then,  only  by 


INTRINSIC  FACTORS  OF  SPEECH 


139 


the  former  or  by  both  together.  This  law  possesses  as  great  a 
value  in  the  questions  concerning  the  aphasias  as  in  psychology. 

The  other  law  exhibits  the  individual  varieties. 

From  this  point  of  view,  we  must  divide  man  into  two  categories. 
The  first  includes  the  illiterate,  still  very  numerous  amongst  us, 
and  the  second  embraces  those  who  have  learned  to  read  and 
write.  In  the  first  category,  the  mechanism  of  language  is  by  far 
the  simpler.  In  the  individuals  comprising  it,  only  the  images  of 
objects  and  abstract  conceptions  come  into  play,  and  these  in  their 
turn  reawaken  the  respective  phonetic  images  by  determined 
paths,  and  these  again  the  motor  images,  which  resolve  themselves 
into  co-ordinate  movements  of  the  whole  apparatus  for  the  articula- 
tion of  speech. 


7 


Fig.  46. 

I,  Image  of  the  object  ; A,  verbal 
acoustic  image  ; M,  motor  image  ; M', 
nervo-muscular  apparatus  for  articula- 
tion ; V,  centripetal  paths  for  the 
formation  of  the  verbal  acoustic  images. 


Fig.  47. 

A,  Acoustic  verbal  image;  M,  motor 
image  ; I,  intellectual  field  ; IM,  direct 
paths  from  the  intellectual  field  to  the 
centre  of  the  kinaesthetic  images  of 
speech  ; the  rest  as  in  Fig.  46. 


Scheme  of  Language  in  the  Illiterate.— first  scheme  (Fig.  46) 
indicates  the  mechanism  of  speech  in  the  individuals  of  this  cate- 
gory. 

In  the  second  scheme  (Fig.  47),  the  field  of  the  intellect  is  also 
directly  connected  with  the  kinaesthetic  centre  ; this  must  be 
considered  probable. 

The  acoustic  image  A is  transmitted  as  a nerve  wave,  which 
arouses  the  correlative  motor  image  in  M,  which,  in  its  turn,  trans- 
mits itself  as  the  nerve  wave  MM^.  The  same  verbal  image  A 
concurs  in  the  formation  of  the  conceptions,  and  reawakens  what 
It  expresses,  or  the  images  of  the  object  to  which  it  refers,  by  travers- 
ing the  path  AT  This  happens  when  we  listen  to  one  speaking, 
or  in  the  so-called  expressive  language.  In  expressive  language, 
the  nerve  wave  departs  from  I (conceptions  and  concrete  images  of 
objects),  and  while  on  one  hand  it  puts  M into  a state  of  tension  by 


140 


PSYCHIATRY 


means  of  the  path  IM,  it  reawakens  the  acoustic  image  of  the  cor- 
relative word  in  A by  means  of  the  path  lA,  and  it  is  the  acoustic 
image  which  becomes  transmitted  along  the  path  AM  as  a nerve 
wave  to  M,  where  it  reawakens  the  kinaesthetic  image  of  the  word, 
which  transforms  itself  into  the  articulated  word  by  the  path  M'. 

In  the  other,  however,  the  mechanism  becomes  extremely 
complex,  inasmuch  as  there  are  associated  with  those  two,  other  two 
factors,  which  in  individual  cases  assume  different  values. 

Just  as  the  study  of  embryology  sheds  an  immense  flood  of 


A F 

Fig.  48. — Scheme  OF  the  Mechanism  of  Language  in  Men  who  Read  and 

Write. 

C,  Field  of  the  concrete  images  and  of  the  conceptions  ; F',  centre  of  the  phonetic 
or  acoustic  images  of  speech  ; V',  centre  of  the  visual  images  ; A',  centre  of  the 
kinaesthetic  articulatory  images  ; G',  centre  of  the  kinaesthetic  graphic  images  ; 
FF'  and  VV',  centripetal  paths  for  the  waves  forming  the  respective  sensory  images  ; 
A'A  and  G'G,  centrifugal  subcortical  paths  for  the  waves  expressive  of  spoken  and 
written  language  ; CV',  CF',  CA',  CG',  associative  paths  between  the  intellectual 
field  and  the  respective  verbal  centres.  (These  paths  must  be  considered  as  twofold, 
from  the  intellectual  field  to  the  verbal  images  and  vice  versa.)  The  other  lines 
represent  the  associative  paths  between  the  different  sensory  and  motor  centres  of 
speech. 


light  upon  ordinary  physiology  and  pathology,  so  does  the  study  of 
the  progressive  development  of  language,  considered  in  general  or 
in  single  races,  or  in  the  infancy  of  each  individual,  shed  an  unex- 
pected flood  of  light  upon  the  physiology  and  pathology  of  language. 

Let  us  follow  the  phases  seen  in  the  infant  in  its  earliest  educa- 
tion in  reading  and  writing.  The  graphic  symbols,  the  letters,  the 
syllables,  and  the  words,  have  their  correlatives  in  the  phonic  symbols 
which  the  infant  already  knows  when  it  is  set  to  learn  to  read. 
There  is  established  in  consequence  of  the  well-known  scholastic 
methods  a relation  between  the  acoustic  image  and  the  visual 
image  of  speech,  with  a preponderance  of  the  former  over  the 


INTRINSIC  FACTORS  OF  SPEECH 


141 

latter,  because  the  graphic  image  has  no  signification  in  the  infant, 
except  such  as  is  due  to  the  phonic  image.  The  association  is  so 
strict,  and  the  relations  between  the  two  so  intimate,  that  the 
visual  image,  being  of  later  acquisition,  can,  in  the  majority  of 
cases,  with  difficulty  act  by  itself  or  be  rearoused  by  itself  under 
the  influence  of  the  concrete  image  of  the  object,  unless  with  the 
aid  of  the  phonic  image,  which  is  aroused  simultaneously,  if  not 
first. 

This  explains  the  scanty  power,  in  most  individuals,  of  the 
visual  image  in  the  mechanism  of  language  ; what  little  it  has  is 
due  to  the  phonic  image.  In  other  words,  it  is  like  the  interlocking 
of  two  cogwheels. 

But  this  rule  does  not  always  hold  good.  Heredity,  education, 
business,  and  exercise,  as  well  as  certain  other  contingencies  of  life, 
can  reinforce  the  visual  images  to  such  a degree  that,  in  the  evolu- 
tion of  speech,  they  assume  a great  predominance  over  the  acoustic. 
In  such  a case  a man  speaks  and  writes,  not  with  the  acoustic 
images,  now  of  secondary  importance,  but  with  the  visual  images. 
The  internal  diction,  so  well  delineated  by  Strieker  and  Ballet,  and 
which  is  so  great  a part  of  language,  is  more  visual  than  acoustic. 
Hence  the  rational  and  happy  distinction  of  men  into  aural  (those 
who  speak  and  write  with  the  acoustic  images  of  words)  and  visual 
(those  who  speak  and  write  preferably  with  the  visual  images  of 
words). 

It  is  evident  that  the  regulative  power  exercised  by  the  acoustic 
images  of  words  over  all  the  others  must  be  assumed  in  part  by  the 
visual  when,  through  long  exercise,  these  acquire  that  potency 
which,  in  persons  who  read  much  less,  must  belong  to  the  auditory 
images.  It  is  likewise  clear  that  the  complex  symptomatology  of 
any  disorder  of  speech  whatever  must  exhibit  notable  differences 
according  as  the  regulative  power  is  exercised  by  one  or  other  of 
the  two  groups  of  cortical  units  whence  are  derived  the  physiological 
factors  of  language  of  which  we  have  spoken  above.  We  can  picture 
to  ourselves  language  as  a constellation,  a planetary  system,  formed 
by  one  star  of  greater  magnitude  and  a number  of  smaller  ones 
whose  movements  are  regulated  by  the  centre  of  the  sidereal  system, 
with  this  difference — that  in  different  individuals  minor  stars 
assume  different  grandeur,  the  visual  in  particular  tending  to 
become  the  centre  of  the  system. 

The  articulation  of  a word  on  the  part  of  a visual  individual 
brings  into  action  (i)  the  phonetic  centre,  where  are  n ised  the 
acoustic  images  of  letters  and  words,  possibly  distir.  (2)  the 

visual  centre,  where  the  visual  graphic  images  of  singl  ’.ers  and 

of  concrete  words  are  reawakened  ; (3)  the  kinaesthetic  : ulatory 

centre,  where  are  reawakened  the  kinaesthetic  image  > <it  is  to 
say,  the  tactile  and  muscular  images  of  all  the  movemen  t i .cessary 
for  the  pronunciation  of  the  letters  and  syllables  of  the  • > d — and. 


142 


PSYCHIATRY 


if  this  is  committed  into  writing,  (4)  the  kinsesthetic  graphic  centre  i 
(register  of  the  tactile  and  muscular  images  occurring  in  the  move-  ! 
ments  of  writing  the  letters  and  syllables  constituting  the  word),  I 
not  admitted  by  any  other.  ! 

The  system  once  constituted  and  the  dynamic  relations  between 
the  various  components  being  established,  it  is  clear  that  the  dis-  * 
appearance  of  one  of  them  must  induce  a disorientation  in  the 
motion  and  direction  of  all  the  others.  It  is  clear,  also,  that  the 
greater  the  regulative  power  which  the  one  exercises  over  the  others, 
the  greater  will  be  the  disorder.  The  suppression  of  the  acoustic 
image  F'  in  the  majority  of  individuals  induces  also  inhibition  of 
the  reproduction  of  the  visual  image,  the  kinaesthetic  articulary 
image,  and  the  kinaesthetic  graphic  image  of  the  word.  The  dis-  ! 
appearance  of  the  visual  image  must  result  in  the  functional  in-  ' 
capacity  of  the  kinaesthetic  graphic  centre  of  the  word,  and  hence  i 
the  inability  to  reproduce,  in  writing,  the  graphic  image  of  the  j 
same,  for  the  very  simple  reason  that  the  graphic  centre  fuhc-  | 
tionates  under  the  more  immediate  control  of  the  visual  image  of  ; 
the  word,  which  it  exhibits  in  sensible  form.  Often,  however,  it  j 
induces  also  a functional  disorientation  of  the  phonic  centre  of  I 
speech,  habituated  as  it  is  to  functionate  in  concert  with  the  visual, 
and  also  a significant  disorientation  of  the  kinaesthetic  centres  of  | 
articulation,  the  greater  the  higher  the  degree  of  evolution  reached 
by  the  visual  word  centre. 

Functional  Solidarity  and  Individual  Specificity  of  the  Different 
Neuro-psychic  Factors  of  Language. — The  complexity  of  the  disorder:! 
brought  to  light  by  delicate  investigation,  no  matter  what  may  be 
the  centre  destroyed,  phonic,  visual,  or  kinaesthetic  articulatory,  t 
along  with  the  progressive  restriction  of  the  number  of  simple  dis-“' 
orders  of  language,  if  partly  the  necessary  consequence  of  the  law  ' 
of  solidarity  among  the  various  factors  of  language,  does  not  detract 
from  any  of  them  that  individuality  which  is  conferred  on  each  by’’ 
the  specific  nature  of  its  own  functional  product.  |! 

According  to  some,  there  do  not  exist  true  centres  of  auditory,|| 
visual,  and  motor  images  of  speech.  Those  we  have  considered  as 
such  are  only  circumscribed  regions  of  the  auditory  or  visual  zonOj; 
which  are  connected  with  the  motor  centre  of  language.  The 
auditory  and  visual  word  images,  as  all  the  others,  would  be  fixed, 
not  by  the  centres  of  reception,  but  in  other  sites  (Sollier). 

The  destruction  of  these  other  centres,  which,  after  all,  would  be, 
according  to  this  idea,  associative  centres,  produces  word  deafness 
and  word  blindness,  because  in  this  case  we  are  dealing  with  destruc- 
tion not  of  the  centres  of  the  images,  but  of  the  centres  for  the 
transmission  of  vibrations,  which  determine  a particular  molecular 
state  corresponding  to  the  internal  or  external  excitation. 

The  reproduction  of  the  images  of  memory  would  occur  through 
the  medium  of  the  motor  or  sensory  functional  centres.  Such  is 


TOPOGRAPHY  OF  SPEECH  CENTRES 


143 


the  theory  held  by  Sollier.  It  has  as  many  obscure  points  as  there 
are  points  associated  with  language,  and  it  is  but  a slight  modifica- 
tion of  the  doctrine  of  Flechsig.  We  shall  return  to  it  again  in  the 
chapter  on  disturbances  of  perception  and  memory. 

We  already  know  the  probable  limits  of  the  sensory  and  motor 
areas  on  the  cortex  of  the  cerebrum.  It  remains  now  to  deal  with 
the  topography  of  the  centres  of  the  sensory  and  motor  images  of 
speech.  The  essential  fact  is  that  these  areas  are  found  on  the 
periphery  of  the  respective  sensory  and  motor  zones,  and  as  the 
office  they  fulfil  represents  a stage  of  functional  evolution  with 
respect  to  the  general  function,  I have  for  some  time  termed  them 
the  zones  of  evolution.  If  we  consider  the  cerebral  mantle  in  rela- 
tion to  its  philogeny  and  ontogeny— functional  and  perhaps  also 
anatomical  we  find  that  each  sensory  or  motor  area  is  separated 
from  its  neighbour  by  an  intermediary  zone  to  which  we  can  assign 
a function  higher  and  more  complex,  in  so  far  as  it  reflects  forma- 
tion and  manifestation  of  thought.  These  intermediary  zones  are 
the  areas  specially  concerned  in  language.  One  is  found  in  the 
general  auditory  sphere,  another  at  the  limits  of  the  general  visual 
sphere,  one  or  two  others  between  the  motor  area  properly  so-called 
and  the  prefrontal  lobe,  a zone  of  evolution  of  the  motor  area.  The 
conception  of  an  area  of  evolution  arises  from  the  fact  that  the 
angular  gyrus  and  the  supramarginal  convolution  in  the  illiterate 
—granted  that  to  this  area  is  relegated  the  formation  and  pre- 
servation of  the  visual  images  of  the  letters  and  words  by  which 
one  learns  to  read — represent  a neutral  zone,  or,  as  one  might  say, 
a blank  register  on  whose  pages,  through  circumstances  of  life,  the 
individual  has  written  nothing.  It  necessarily  follows  that  de- 
struction of  this  area  does  not  occasion  the  suppression  of  any  func- 
tion, or  diminish  in  any  way  the  intellectual  capital  of  him  who  is 
thereby  deprived  of  it.  Now,  when  it  is  borne  in  mind  that  the 
optic  area,  or  field  of  cortical  projection  of  the  retina,  comprises  the 
calcarine  fissure,  part  of  the  lingual  and  fusiform  lobules,  and  the 
occipital  pole,  and  that  the  external  aspect  of  the  occipital  lobe  is 
the  probable  seat  of  concrete  visual  images  of  objects  and  perhaps 
also  of  places,  and  that  it  must  be  more  or  less  occupied  in  different 
individuals  according  to  the  opportunities  they  have  had  by  educa- 
tion and  vocation  of  recording  a greater  or  less  number  of  impres- 
sions, it  will  on  all  hands  be  admitted  that  the  rest  of  the  visual  area 
is  a zone  of  evolution,  a blank  register  for  recording  images  of  a 
higher  value,  with  a particular  education,  enormously  augmenting 
the  mtellectual  capital,  versatility,  and  influence  of  the  individual 
m his  social  relations.  The  fact  is  that  lesions  of  this  zone  in  the 
illiterate,  if  they  extend  in  depth  as  far  as  the  radiations  of  Gratiolet, 
induce  only  bilateral  homonymous  hemianopsia,  and  perhaps  some 
disturbance  in  the  associative  process,  through  interruption  of  other 
paths  of  association  between  distant  cortical  regions  ; while  in 


144 


PSYCHIATRY 


those  who  have  learned  to  read  the  same  lesions  produce  also  loss 
of  reading.  Furthermore,  as  every  new  and  high  function  of  the 
cerebrum,  and  especially  that  of  language,  plays  an  important  part 
in  the  process  of  thought  and  in  the  government  of  psychic  life, 
the  destruction  of  that  same  area  of  language,  whose  function  would 
be  highly  developed,  will,  in  consequence,  cause  also  a more  or  less 
serious  disturbance  of  the  process  of  thought. 

What  I have  said  of  the  visual  area  of  language  holds  good  also 
of  the  others.  The  law  is  similar,  the  only  difference  being  in  the 
period  of  development  of  each  area,  and,  in  consequence,  the  im- 
portance, as  regards  the  mechanism  of  speech,  which  is  to  be  attri- 
buted to  each  in  the  history  of  the  individual  development. 

The  auditory  area  or  register  of  the  acoustic  word  images  is 
found  in  the  middle  and  posterior  parts  of  the  first  temporal  con- 
volution, and  perhaps  also  of  the  second. 

The  motor  area  of  articulate  speech,  the  field  of  formation  and 
registration  of  the  kinaesthetic  images  of  articulate  speech,  is  found 
at  the  base  of  the  third  frontal  convolution,  the  so-called  centre  of 
Broca — strictly  speaking,  that  part  of  the  base  which  is  embraced 
between  the  vertical  and  anterior  horizontal  branches  of  the  fissure 
of  Sylvius. 

The  motor  area  of  written  speech  or  register  of  the  kinaesthetic 
images  of  writing  would  occupy  the  base  of  the  second  frontal  con- 
volution. As  is  well  shown  in  the  figure,  the  two  sensory  areas  of 
speech — the  auditory  and  the  visual — are  found  each  to  form  a 
part  of  the  corresponding  visual  and  auditory  sensory  areas,  each 
being  a continuation  of  the  respective  general  areas. 

The  motor  areas  of  speech  are  situated  each  in  continuation 
with  the  respective  general  motor  areas ; that  of  articulate  speech 
near  the  area  for  the  movements  of  the  face,  jaw,  tongue,  larynx, 
etc.  ; that  of  written  speech  near  the  area  for  the  movements  of 
the  arm,  wrists,  hand,  and  fingers  (fronto  - Rolandic  evolutive 
area).  ' 

This  manner  of  viewing  the  topography  of  the  areas  of  language  i 
appears  to  be  truer  and  more  rational  than  the  other,  which  con-  i 
siders  language  as  a function  of  the  convolutions  of  the  fissure  of  \ 
Sylvius. 

It  is  known  that  in  the  first  instance  Charcot,  and,  after  him, 
Freund,  located  the  centres  of  language  on  the  convolution  bound- 
ing the  fissure  of  Sylvius  above,  behind,  and  below.  To  this  region 
Freund  gave  the  name  of  ‘ the  zone  of  language,’  but  it  would  appear 
rather  circumscribed  behind,  above,  and  below,  with  respect  to  the 
entire  boundary-line  of  the  Sylvian  fossa,  and  to  the  great  distance 
which  divides  that  zone  from  the  motor  area  of  articulate  speech. 
But  Mirallie  and  Dejerine  would  also  justify  the  denomination  on 
the  ground  that  in  the  subcortical  substance  of  the  opercular  tract,  j 
which  would  have  nothing  to  do  with  language,  associative  fibres  ! 


TOPOGRAPHY  OF  AREAS  OF  LANGUAGE 


145 


would  pass  between  the  different  centres — above  all,  between  the 
sensory  centres  and  the  motor  centre  of  speech. 

Apart  from  the  fact  that  these  paths  are  by  no  means  demon- 
strated in  the  opercular  tract,  I do  not  attach  any  importance  to 
the  belief  that  such  centres  may  be  situated  around  the  fissure  of 
Sylvius,  or  that  they  are  all  nourished  by  the  Sylvian  artery. 
When  we  consider  that,  for  the  reasons  above  stated,  there  in  all 
probability  exists  a centre  for  the  movements  of  writing  at  the  base 
of  the  second  frontal  convolution  ; that,  in  the  illiterate,  the  supra- 
marginal convolution  and  the  angular  gyrus  are  of  little  account  in 
physiology  and  pathology  ; that  the  associative  paths  from  the 
visual  to  the  motor  zone  are  represented,  not  by  a compact  bundle 
in  the  subopercular  substance,  but  by  paths  scattered  over  a large 


Fig.  49. — Topography  of  the  Zone  of  the  Neuro-psychic  Factors  of 

Language, 

A,  Acoustic  zone  ; V,  visual  zone  ; P,  motor  zone  for  spoken  language  ; S,  pre- 
sumed motor  zone  for  writing  ; I,  intellectual  field,  which  in  the  scheme  is  repre- 
sented only  by  the  frontal  lobe,  but  comprises  all  the  sensory  zones,  whose  reci- 
procal relations  with  the  field  of  speech  have  been  suppressed  so  as  not  to  complicate 
the  figure  to  such  an  extent  as  to  render  it  less  intelligible. 


fronto-parieto-occipital  surface  ; that  the  paths  between  the 
auditory  and  the  motor  areas  of  language,  apart  from  the  insula, 
can  only  be  those  of  the  capsula  extrema  and  capsula  externa  ; and 
also  that  the  associative  paths  between  the  intellectual  field  and 
the  field  of  the  neuro-psychic  factors  of  speech  form  a part  of  the 
zone  of  language,  no  one  can  attach  importance  to  the  statement 
that  the  Sylvian  region  is  the  sole  zone  of  language,  more  especially 
as  such  a tendency  to  restrict  within  very  narrow  limits  very  wide 
functions  cannot  but  be  dangerous,  as  much  to  the  scientific  concep- 
tion of  the  function  itself  as  to  the  anatomical  diagnosis  of  the 
various  forms  of  aphasia. 

Figure  49  shows  clearly  how  the  various  centres  of  speech  are 
related  to  one  another,  so  as  to  exchange  their  respective  products 
according  to  the  laws  previously  alluded  to,  arid  sets  forth  their 

10 


146 


PSYCHIATRY 


connection  at  the  same  time  with  the  intellectual  field.  The  motor 
centres  for  language  are  dependent  on  the  sensory  centres,  because 
in  the  majority  of  cases  it  is  the  sensory  images,  auditory  and 
visual,  which  put  the  motor  centres  in  action,  while  at  the  same 
time  they  are  in  relation  with  the  intellectual  field,  which,  on  the 
other  hand,  gives  the  re-evocative  impulse  to  the  sensory  centres 
A and  V.  Pitres,  on  the  other  hand,  holds  that  the  idea  evokes 
speech  directly,  without  the  intervention  of  the  sensory  centres. 

It  is  an  opinion  which  one  cannot  absolutely  contradict,  and  if  a 
distinct  field  for  the  intelligence  in  direct  relation  with  the  motor 
centres  be  admitted — while  one  holds  that  most  people  are  motor- 
phonetic  rather  than  auditory  and  visual — then  there  can  be  no 
difficulty  in  believing  that  the  idea  awakens  the  word  directly  in 
P.  I am  not  averse  to  sharing  a similar  opinion  ; but  one  must  agree 
that  the  function  is  very  complex,  and  that  the  scheme  gives  but  a 
very  faint  idea  of  it.  It  would  certainly  be  difficult,  by  accepting 
unconditionally  such  a view,  to  explain  the  paraphasia  resulting 
from  a lesion  of  or  of  the  associative  fibres  AP,  with  P quite 
normal  and  in  regular  relation  with  /. 

All  the  fore-mentioned  centres  of  language  are  found,  in  the 
majority  of  cases,  in  the  left  hemisphere.  The  right  cerebrum, 
however,  is  in  some  the  seat  of  the  functions  of  language,  inasmuch 
as  it  is  also  the  seat  of  the  more  specialized  volitional  centres,  as  ■ 
in  left-handed  people.  Right-handed  individuals  always  speak  . 
from  the  left  hemisphere,  while  left-handed  speak  from  the  right.  ;| 
The  latter  form  an  exception  to  the  general  rule.  Preobraschenski,  :| 
to  give  an  example,  has  recently  published  the  case  of  a left-  | 
handed  individual  with  left  hemiplegia  and  motor  aphasia  due  to  ? 
a gross  lesion  in  the  right  hemisphere.  The  right  hemisphere  assists  ‘ 
but  little  in  the  function  of  language,  symbolic,  spoken,  or  written.  ■ 
It,  however,  bulks  more  largely  in  emotional  language.  Later  on  -i 
it  may  possibly  acquire  importance  in  those  who,  from  disease  of 
the  left  hemisphere,  have  lost  the  function  of  language. 

As  the  centres  of  the  right  and  the  left  hemispheres  are  homo- 
logons  and  in  communication  with  each  other,  it  is  easy  to  under-  ij 
stand  how,  under  some  circumstances,  particularly  in  children,  these  J 
functions,  which  by  heredity  are  usually  differentiated  on  the  left 
hemisphere,  become  specialized  on  the  right.  The  hypothesis  of 
the  education  of  the  right  hemisphere  to  the  function  of  language 
is  accepted,  however,  with  reserve,  because  the  re-education  of  the 
aphasics  is  also  due  in  some  measure  to  the  parts  near  the  destruc- 
tive focus,  seeing  that  the  respective  centres,  which  are  seldom  com-  , 
pletely  destroyed,  are  not  definitely  delimited  from  the  neighbouring 
areas,  but  are  surrounded  by  an  evolutive  zone  which,  if  spared, 
can,  in  part  at  least,  take  up  the  function  of  the  region  destroyed,  i 

Compensations  in  general — and  in  the  particular  case  of  language  ' 
they  are  not  very  infrequent — can  be  attributed,  on  the  one  hand,  ! 


PREPONDERANCE  OF  LEFT  HEMISPHERE  147 


to  the  development  of  the  function  in  the  evolutive  zone,  or  in  that 
part  of  the  centre  itself  which  is  spared,  and,  on  the  other  hand,  to 
the  function  of  homologous  areas  of  the  right  hemisphere  by  their 
consequently  increased  specialization. 

I will  mention  but  briefly  the  already  much-discussed  question 
why  the  left  hemisphere  is  the  centre  for  articulate  speech,  while 
volitional  movements  are  fulfilled  by  both  hemispheres.  The  more 
generally-accepted  hypothesis  is  that  of  H.  Jackson.  Seeing  that 
the  right  side  of  the  body,  through  atavism  and  through  individual 
education,  is  that  which  is  most  generally  employed,  it  is  clear  that 
the  left  hemisphere  acquires  a significant  preponderance  over  the 
right  in  all  motor  functions,  and  possibly  too  in  psychic.  Language 
is  the  highest  expression  of  this  preponderance  of  the  left  hemisphere. 
Whether  the  particular  mode  of  origin  of  the  left  carotid  artery 
determines  in  advance  the  development  of  the  left  cerebral  hemi- 
sphere as  compared  with  the  right  is  a question  which  cannot  be 
conclusively  answered  ; it  is  affirmed  by  Ogle  and  by  Gratiolet,  and 
negatived  by  Vogt  and  Ecker.  To  me,  however,  the  preponder- 
ance in  weight  of  the  left  hemisphere,  in  relation  to  its  psycho- 
linguistic  function,  appears  to  be  an  indisputable  fact. 

When  the  child  accompanies  its  first  articulate  sounds  with  a 
gesture  of  the  right  hand,  it  engraves  on  the  left  hemisphere  the 
first  association  between  the  word  spoken  and  the  movements  of 
the  right  upper  limb.  We  work,  write,  practise  self-defence,  etc., 
with  the  right  upper  limb,  and  as  this  limb  acts  oftener  and  more 
efficiently  than  the  left,  hence  also  the  left  hemisphere  must  function- 
ate more  frequently  and  to  better  purpose  than  the  right.  This 
functional  development  must  also  produce  great  anatomical  growth 
of  the  left  hemisphere,  and  it  is  to  this  same  agency  that  the  par- 
ticular localization  of  speech  in  the  left  hemisphere  is  due.*  For 
those  learning  to  read,  the  committal  to  paper,  in  graphic  symbols 
with  the  right  hand,  of  labial  and  syllabic  sounds  spoken  in  a loud 
or  clear  voice,  as  is  often  the  case  with  infants,  is  not  without  im- 
portance. The  right  hemisphere,  however,  is  not  altogether  denied 
a part  in  the  function  of  language,  but  plays  rather  an  important 
part  in  the  execution  of  the  first  articulate  sounds  of  the  infant,  a 
period  in  which  language  is  more  emotional. 

Kussmaul,  Bastian,  Wyllie,  and  H.  Jackson  agree  as  to  the 
part  taken  by  the  right  hemisphere  in  the  formation  and  exposition 
of  language. 

As  differentiation  of  ideas  and  their  connections  with  words 
progress,  the  left  hemisphere  increases  in  activity,  while  the  right 
lags  behind. 

The  majority  of  men  speak  with  the  left  hemisphere.  Seguin’s 
collection  of  17  aphasics  with  left  hemiplegia,  contrasted  with 

* The  greater  weight  of  the  left  hemisphere  has  for  a long  time  been 
demonstrated  by  Bastian,  Turner,  Nicolucci,  and  others. 


10 — 2 


148 


PSYCHIATRY 


240  aphasics  with  right  hemiplegia,  corresponds  to  little  more 
than  the  proportion  of  left-handed  individuals  which  Ogle  found 
in  2,000  ordinary  patients  examined  by  him  in  this  connection. 
Notwithstanding,  the  right  hemisphere,  as  we  have  already  seen,  is 
not  altogether  devoid  of  the  mechanism  of  language,  to  which  it 
gives  its  contribution.  I maintain  that,  as  regards  speech,  the 
right  hemisphere  is  as  yet  in  an  elementarv  stage  of  development 
as  compared  with  the  left. 

Thus  it  is  that  aphasics  can  utter  incomplete  and  odd  words 
as  well  as  some  monosyllables,  which  all  have  noted,  and  can  speak 
the  inter] ectional,  primitive  form  of  language.  Does  the  right 
hemisphere  co-operate  in  the  articulation  of  these  organized  sounds, 
such  as  oaths  and  the  commoner  words,  ‘ yes  ’ and  ‘ no  ’?  That  it 
does  is  the  opinion  which,  as  I have  already  said,  is  most  accepted. 
In  fact,  in  the  literature  of  the  subject  there  are  recorded  cases 
which  indicate  that  the  aphasia  is  more  pronounced  when  the 
lesions  are  bilateral.  Thus  Vernet’s  patient,  who  on  the  left  side 
had  only  a haemorrhagic  focus  in  the  insula,  was  completely  aphasic,  a 
point  which  can  only  be  explained  by  the  existence  of  another  focus 
on  the  right  side  affecting  the  foot  of  the  third  frontal  convolution. 
The  actual  facts  are  that  left-handed  individuals  become  aphasic 
through  destructive  foci,  not  in  the  left,  but  in  the  right  hemisphere 
(Wadham’s  and  Habershon’s  cases)  ; further,  that  lesions  of  the 
zone  of  language  on  the  left  side  do  not  produce  aphasia  in  left- 
handed  individuals  (cases  recorded  by  Taylor,  Foulis,  Westphal, 
Wolland,  Bianchi,  and  Seppilli)  ; and  that  between  the  centres  of 
speech  in  the  left  and  the  homonymous  parts  in  the  right  hemisphere 
there  exist  commissural  fibres. 


From  what  we  have  thus  far  discovered  it  is  clear  that  percep- 
tion, which  furnishes  all  the  elements  necessary  for  the  cognition  of 
objects  falling  under  the  senses,  cannot  be  considered  as  the  result 
of  a physiological  process  of  a simple  nature  or  of  processes  simply 
successive  in  time  and  space.  It  is  rather  the  complex  and  co- 
ordinate resultant  of  many  processes  of  different  character,  suc- 
cessive, and  extended  over  the  cerebral  surface.  For  the  visual 
perception  of  an  object  we  now  recognise  that  there  are  requisite, 
as  before  stated — (i)  a luminous  stimulus,  which  is  transformed 
into  a luminous  sensation  ; (2)  a series  of  movements,  the  execution 
of  which  fixes  in  the  corresponding  centre  the  features  of  form, 
extent,  and  special  relations ; (3)  the  fusion  of  these  two  factors, 
whence  is  derived  the  objective  unity  which  gives  to  the  perceptive 
centres  the  image  of  the  object.  Even  although  there  should  be  no 
morphological  difference  between  the  elements  furnishing  these 
various  physiological  components  of  vision,  no  one  would  care  to 
deny  that  these  elementary  factors  differ  from  one  another,  and  that 


EXISTENCE  OF  ASSOCIATIVE  AREAS 


149 

hence  they  may  come  into  action  at  different  points  and  in  different 
nervous  elements. 

What  we  have  said  of  the  visual  zone  and  visual  perception  can 
be  attributed  to  all  the  other  senses  and  to  their  respective  cortical 
areas.  In  the  vicinity  of  the  auditory  zone  is  the  motor  centre 
for  the  auricles,  and  the  auditory  centre  must  also  be  in  relation 
with  the  motor  zone  of  the  head  and  eyes.  In  relation  with  the 
olfactory  area  are  (i)  the  centre  whose  excitation  induces  move- 
ments of  the  nares,  and  (2)  the  respiratory  centre.  We  ought  to 
consider  the  centres  of  the  jaw  and  of  mastication  as  forming  part 
of  the  gustatory  area. 

It  follows  from  the  results  of  experiments  that  we  should 
assign  a very  extensive  area  to  the  visual  function,  and  distinguish 
it  into  regions  set  apart  for  mere  elementary  functions,  and  one 
region  in  which  the  elementary  components  would  be  co-ordinated 
(or  associated)  and  fused,  in  order  to  give  a more  complex  percep- 
tive product,  which  is  that  of  the  concrete  images  of  objects. 

The  idea  of  the  existence  of  associative  zones  had  been  clearly 
expressed  by  me  eighteen  years  ago,  on  an  experimental  basis,  in 
confirmation  of  the  hypothesis  of  Broadbent,  which  had  been 
known  for  several  years  previously.  To  Flechsig,  however,  we  owe 
the  confirmation  and  development  of  this  conception,  which,  having 
its  primary  origin  in  experimental  observation  (although  he  seems 
to  ignore  this  fact),  yet  seemed  to  him  capable  of  being  laid  down  as 
a proposition  on  purely  anatomical  grounds.  According  to  Flechsig, 
the  cerebral  mantle  is  in  relation  with  the  receptive  and  emissive 
organs  by  one  part  only.  This  part  in  its  entirety  is  constituted  by 
the  so-called  sensory  and  motor  cortical  centres,  which  receive 
fibres  of  projection  from  the  sensory  organs,  and  give  origin  to 
centrifugal  fibres  for  the  motor  apparatus.  There  are  consequently 
two  systems  of  fibres  of  projection,  centripetal  and  centrifugal. 
By  means  of  the  receptive  system  the  brain  receives  and  transforms 
the  external  energies  into  psychic  energy  ; by  the  emissive  system 
it  reacts  with  psychic  energy  upon  the  external  world.  This  area, 
possessing  the  most  direct  relations  with  the  periphery,  does  not 
much  exceed  the  third  of  the  entire  surface  of  the  cortex,  according 
to  the  original  calculations  of  Flechsig.  All  the  rest  of  the  cerebral 
mantle,  more  than  the  half  of  its  surface,  though  possessing  scattered 
fibres  of  projection — according  to  Flechsig’s  more  recent  researches, 
with  which  he  seeks  in  a manner  to  correct  his  previous  results — has 
not  such  numerous  and  direct  relations  with  the  periphery  of  the 
body,  but  has  an  indirect  relation  by  means  of  the  areas  previously 
indicated,  and  it  is  divided  into  regions  to  which  Flechsig  has  given 
the  name  of  associative  areas.  These  are  the  areas  that  elaborate 
the  products  of  function  of  the  receptive  areas  and  furnish  pro- 
ducts of  higher  psychic  value  such  as  result  from  the  physiological 
fusion  of  a certain  number  of  simpler  psychic  products. 


150 


PSYCHIATRY 


The  method  of  black  coloration  used  by  Flechsig  has  enabled 
him  to  distinguish  the  first  areas,  which  I call  receptive,  from  the 
second,  which  he  calls  associative.  The  former  receive  fibres  which 
become  myelinated  some  time  before  the  fibres  of  the  second  system, 
which  are  myelinated  more  slowly  and  progressively  from  the 
periphery  of  the  receptive  zones  to  the  terminal  zone,  as  he  calls 
it,  of  the  associative  area.  The  nerve  fibres  with  late  myelination 
come  from  the  receptive  zones,  a fact  which  allows  us  to  deduce, 
with  the  greatest  probability,  that  in  the  areas  called  associative 
the  products  of  work  of  the  receptive  areas  or  areas  of  projection 
become  elaborated.  According  to  Flechsig,  the  associative 


lamporaL  nr^u.  Awdttory  Area 

Fig.  50. — Distribution  of  the  Areas  of  Projection  and  Association, 

ACCORDING  TO  FlECHSIG.  ; EXTERNAL  ASPECT. 

areas  on  the  external  aspect  of  the  hemisphere  would  be  three  in 
number  : (i)  The  anterior  or  frontal,  situated  in  front  of  the  motor 
zone,  or,  as  he  calls  it,  the  tactile  zone,  and  comprising  the  prefrontal 
lobe  ; (2)  the  middle,  much  smaller,  is  formed  by  the  insula,  situated 
between  the  frontal  lobe,  the  olfactory,  the  somaesthetic,  and  the 
auditory  zones  ; (3)  the  large  posterior  or  parieto-occipital  asso- 
ciative zone,  rather  larger  than  the  two  preceding,  comprising 
an  extensive  surface,  limited  in  front  and  above  by  the  som- 
aesthetic  zone  ; in  front,  below,  and  above  (on  the  internal  aspect) 
by  the  insula,  the  auditory  and  the  olfactory  zone  (according  to 
some  by  the  gustatory  as  well)  ; behind  by  the  optic  zone  ; below, 
it  is  continued  on  the  inferior  aspect  of  the  hemisphere  as  far  as  the 
hippocampus. 


FLECHSICS  DOCTRINE  OF  ASSOCIATION  151 

In  a succeeding  publication  (Neue  Untersuchungen  ueber  die 
Markhildung  in  den  menschlichen  Grosshirnlappen  — Neurolog. 
Centralhl,  1898),  Flechsig  had  to  recognise  from  the  results  of  his 
researches,  carried  out  with  the  method  before  mentioned,  and  with 
the  view  of  discovering  the  moment  of  appearance  of  myelination 
of  the  intrahemispheric  nerve  fibres  during  the  development  of  the 
brain  in  intra-  and  extra-uterine  life,  a much  greater  number  of 
special  zones,  designated  by  him  ‘ embryological  cortical  territories.’ 
He  distinguishes  forty  of  them,  and  believes  that  this  number  is 
not  exhaustive.  Such  a large  number  of  cortical  territories  is  dis- 


Fig.  51. — Distribution  of  the  Areas  of  Projection  and  Association, 

ACCORDING  TO  FlECHSIG  I INNER  ASPECT. 

tributed  in  three  groups  : (i)  Primordial  which  are  nor- 

mally formed  before  the  foetus  reaches  maturity  (from  Nos.  i 
to  8 of  his  system)  ; (2)  intermediate  territories,  the  fibres  of  which 
become  myelinated  up  to  one  month  after  parturition  at  term  (from 
9 to  32)  ; and  (3)  terminal  territories,  the  fibres  of  which  are  maturing 
from  one  to  four  months  after  birth  (from  33  to  40). 

The  physiological  signification  of  the  given  associative  areas  is 
not  easy  to  define.  The  author  assigns  to  his  anatomical  researches 
a much  wider  signification  than  they  really  merit,  giving,  as  he  does, 
to  his  system  the  appearance  of  a structure  reared  upon  the  sound 
and  stable  foundatioii  of  anatomy.  It  is  evident,  however,  that 
cortical  psycho-physiology  incurs  a danger  if  we  trust  to  suggestive 
anatomical  inquiries  on  the  too  exclusive  method  adopted  by 


or  ^onas.s,t/iet/ 


Olfactory  Area 


152 


PSYCHIATRY 


Flechsig,  who,  in  point  of  fact,  is  contradicted  by  Vogt,  who  has 
been  unable  to  confirm  the  postulates  of  Flechsig  as  regards  either 
the  chronological  or  the  topographical  order  of  the  myeline  invest- 
ment of  the  nerve  fibres. 

The  anatomical  connection  between  the  various  centres  of  sen- 
sibility in  the  cortex  would  take  place  through  the  medium  of  the 
centres  of  association,  and  more  particularly  through  that  of  their 
marginal  zones,  by  means  of  the  arcuate  fibres.  The  centres  of 
association,  in  other  words,  would  have  the  task  of  associating  and 
reproducing  the  states  of  excitation  of  the  different  spheres  of  sen- 
sibility, indirectly  uniting  these  spheres  with  one  another,  by  means 
of  the  system  of  fibres  of  association. 

The  more  feasible  deduction  which,  though  not  exactly  formu- 
lated, one  can  read  between  the  lines  of  the  different  communications 
on  this  subject  by  Flechsig  is  that  each  embryological  cortical 
territory  of  all  three  groups  possesses  distinct  physiological 
features  of  its  own,  and  one  must  come  to  the  conclusion  that 
the  forty  territories,  which  for  some  time  hence  will  be  increased 
in  number,  serve  for  correspondingly  specific  activities  of  the 
mind. 

When  one  considers  such  an  important  anatomical  and  physio- 
logical problem  without  prejudice  and  intolerance  of  mind,  such  as 
emanate  from  the  publications  of  Flechsig,  the  hrst  question — in 
itself  very  elementary — that  presents  itself  to  the  mind  is  the 
following  : Does  the  myelination  of  the  intrahemispheric  fibres 
always  obey  a constant  law  ; and,  if  so,  does  it  follow  as  an  unfailing 
corollary  that  this  topography  of  evolutive  anatomy  should  be 
retained  as  a foundation  and  support  of  a kind  of  psychological 
topography  ? Indeed,  there  is  nothing  to  prevent  us,  j udging  from  the 
m.odifications  made  by  Flechsig  himiself  in  his  original  scheme,  con- 
cluding that  the  maturing  of  the  intrahemispheric  fibres  does  not 
follow  a law  so  constant  in  its  details  as  to  justify  the  new  cortical 
topography.  This  is  in  the  way  of  being  proved,  as  I have  already 
recorded.  In  this  case  the  intermediate  and  terminal  territories  would 
not  possess  specific  m,ental  activities  in  the  sense  of  Flechsig,  but  with 
their  maturity  there  would  coincide,  at  the  most,  the  evolutionary 
extension  of  a function  already  represented  in  the  neighbouring  terri- 
tories, and  one  might  then  m.aintain  that  each  forms  a part  of  the  re- 
spective sensory  or  primordial  territory,  of  which  it  would  represent 
only  an  evolutionary  extension.  In  other  words,  we  may  logically 
suppose  that  what  Flechsig  regards  as  associative  areas  are  only 
perceptive  areas  progressively  more  evolved,  with  the  exception  of 
the  anterior,  which  we  will  deal  with  specially.  This  leads  us  to 
admit  zones  of  evolution  towards  the  limits  of  each  sensory  or  per- 
ceptive area. 

On  the  other  hand,  it  is  well  to  mention  that  it  is  neither  proved 
nor  probable  that  centres  of  memory  exist  in  the  cerebral  cortex 


FLECHSIGS  DOCTRINE  CRITICISED 


153 


distinct  from  those  we  call  perceptive  centres.  If  we  support  the 
uniformity  of  the  anatom.ical  substratum  of  the  perceptions  and 
of  the  images  com.memorative  of  past  perceptions  — that  is  to 
say,  of  the  images  of  objects  which  have  stimulated  the  senses — 
we  arrive  at  the  inference  that  the  perceptive  zone  is  only  the  zone 
of  the  memory  of  past  perceptions.  I have  already  pointed  out 
that  we  mmst  give  a rnmre  rational  interpretation  to  the  perceptive 
process. 

The  undisputed  fact  of  the  association  of  different  images 
for  the  form.ation  of  complex  images  and  general  ideas  obliges  us 
to  admit  the  continuous  movement  of  such  products  from  the  sites 
of  formation  to  the  points  of  rendezvous  ; but,  with  the  exception 
of  the  frontal  lobe,  to  which,  as  we  shall  see  a little  further  on,  we 
must  attribute  this  power  of  synthesis,  it  becomes  arbitrary  to 
affirm  that  the  centre  of  m.em.ory  of  past  perceptions  is  distinct  from 
the  centre  of  perception  (we  shall  examine  this  question  in  greater 
detail  in  the  chapter  upon  m.emory),  as  does  Flechsig,  who  assigns 
the  task  of  associating  the  different  im^ages  to  the  parieto-temporo- 
occipital  zone.  If  this  last  were  distinct  from  the  perceptive  zone, 
and  there  were  situated  in  it,  placed  as  it  is  in  front  of  the  visual 
perceptive  zone,  the  so-called  associative  one  which,  according  to 
Flechsig,  would  be  the  meeting-point  of  the  perceptions  already 
registered  and  those  freshly  furnished  by  the  sensory  zones,  in  which 
would  reside  the  process  of  recognition  and  classification  of  the  per- 
ceptions themselves  ; if  in  such  a zone  there  could  come  together, 
not  only  the  past  visual  perceptions,  but  the  auditory,  the  olfactory, 
and  the  tactile,  with  which  series  of  psychic  com_pounds  of  a higher 
order  might  be  formed,  the  hypothesis  of  Flechsig  with  regard  to 
that  zone  would  be  more  intelligible  and  more  probable  ; but  this 
extensive  surface  of  the  brain  is  almmst  quite  appropriated  by  the 
visual  function.  At  several  points  of  it  electric  excitation  produces 
ocular  movements  ; destruction,  or  partial  destruction,  if  it  is  cortical 
only,  provokes  transient  visual  disturbances  ; if  it  is  deep,  it  pro- 
duces perm.anent  hemiopia  ; if  it  is  bilateral,  psychic  blindness,  in 
which  case  objects  seen  are  no  longer  recognised. 

This  fact  may  be  explained  as  due  to  failure  of  the  anatomical 
substratum  of  the  previously  registered  visual  images,  whose 
mnemonic  reawakening  is  necessary  as  the  standard  of  comparison 
for  their  recognition,  and  to  the  concomitant  failure  of  the  conditions 
requisite  for  formation  and  registration  of  images  seen  for  the  first 
time.  Further,  the  anterior  terminal  extremity  of  the  given  area 
is  in  man  exclusively  visual,  inasmuch  as  it  is  destined  for  a function 
hierarchically  higher,  namely  that  of  reading — that  is  to  say,  the 
function  through  which  the  visual  images  of  the  graphic  symbols 
of  the  words  denominating  the  objects  seen  are  formed  and  registered. 
The  components  of  the  visual  graphic  images  are  much  more 
numerous  compared  with  those  of  the  visual  images  of  the  objects 


154 


PSYCHIATRY 


themselves,  and  therefore  the  given  zone,  physiologically  viewed,  has 
a much  higher  value,  and  must  be  considered  more  fully  evolved, 
yet  of  a visual  nature.  Hence  all  this  large  zone  called  by  Flechsig 
‘ associative  ’ is,  after  all,  only  a region  of  the  cortex  set  apart 
exclusively  for  the  visual  function  in  all  its  gradations,  from  the 
simplest  to  the  most  complex.  And  the  rule  would  be  that  the 
function  is  evolved  from  simple  luminous  perceptions  in  the  region 
of  the  calcarine  fissure,  the  cuneus,  and  the  occipital  pole,  with  the 
aid  of  the  motor  elements  of  the  eyes,  to  the  formation  of  the  images 
of  objects  in  the  cortex  of  the  external  occipito-parietal  aspect,  and, 
finally,  with  this  last  psychic  product,  now  fairly  complex,  it  becomes 
still  further  evolved  up  to  the  formation  of  the  visual  graphic 


Fig.  52. — Distribution  of  the  Primordial,  Intermediate  and  Terminal  • 
Territories,  according  to  the  most  recent  Researches  of  Flechsig  . , 
External  Aspect.  j 

I 

symbols  of  the  objects  themselves  and  their  relations  in  the  region| 
of  the  anterior  limits  of  the  given  zone.  There  is  nothing  to  warrant) 
the  consideration  of  this  extensive  cortical  region  as  the  anatomical 
substratum  of  the  highest  intellectual  processes,  consisting  of  the 
association  of  images  furnished  by  the  different  perceptive  or  sensory 
areas,  because  no  clinical  observation  as  yet  published  favours  such 
a hypothesis.  If  bilateral  lesions  of  the  given  zone  produce,  besides 
psychic  blindness  for  objects,  a more  or  less  marked  condition  of 
dementia,  a fact  which  Flechsig  adduces  in  support  of  his  theory, 
it  is  legitimate  to  suppose  that  the  dementia  in  such  cases  is  the 
expression  of  the  loss  of  a large  part  of  the  intellectual  capital  of 
the  individual,  depending  on  the  destruction  of  the  records  of  the 
visual  images  of  the  external  world,  which  constitute  the  greatest 


FLECHSIG^S  DOCTRINE  CRITICISED 


155 


contingent  of  the  whole  sum  of  the  sensory  psychic  components  of 
the  human  intelligence.  Hence  the  statement  that  excitation  of 
the  sensory  zone  gives  as  the  result  hallucination,  while  that  of  the 
associative  zone,  with  which  we  are  concerned,  induces  mental  con- 
fusion, still  demands  the  approbation  of  facts  and  anatomo-patho- 
logical  proofs  which  cannot  possibly  be  drawn  from  the  objective 
examination  of  our  existing  data,  and  it  ought  therefore  to  be  held 
as  inconclusive.  It  is  sufficient  to  recollect  that,  in  nearly  every 
case,  hallucinations,  when  they  arise  acutely,  induce  states  of 
dementia  (mental  confusion,  amentia)  more  or  less  marked,  and  that 
not  infrequently  there  are  cases  in  which  a single  visual  or  auditory 
hallucination  profoundly  disturbs  the  psychic  personality,  even  to 


Fig.  53. — Distribution  of  the  Primordial,  Intermediate  and  Terminal  Terri- 
tories, ACCORDING  TO  THE  MOST  RECENT  RESEARCHES  OF  FlECHSIG  I InNER 

Aspect. 

the  production  of  intense  mental  confusion  and  sometimes  of  true 
stuporose  conditions.  These  facts  give  to  the  hypothesis  of  Flechzig 
the  value  that  it  merits,  rather  different,  certainly,  from  what  its 
author  would  assign  to  it. 

Histological  analysis  brings  no  aid  to  the  doctrine  of  the  associa- 
tive areas  as  understood  in  the  sense  of  Flechsig.  We  ought  to 
meet  with  simiplicity  of  structure  in  the  sensory  area,  as  compared 
with  the  structure  of  the  associative  areas.  But  the  histological 
data  so  far  collected  do  not  warrant  such  a conclusion.  We  know 
that  the  occipital  lobe,  even  from  the  now  old  researches  of 
Meynert,  has  always  shown  a structure  still  m.ore  complex  (seven 
layers  instead  of  the  five  which  the  motor  zone  would  have).  The 
greater  structural  complexity  of  the  visual  zone  has  been  lately 


PSYCHIATRY 


156 


confirmed  by  Ramon  y Cajal  (E studios  sohre  la  corteza  cerebral 
hmnana — Rivista  trimestral  micrografica,  1899),  who  has  recog- 
nised new  layers.  Thus  far  nothing  has  been  discovered  to  demon- 
strate such  a difference  of  structure  between  the  cell  components  of 
the  sensory  and  associative  zones  as  would  account  for  the  great 
difference  in  function  that  we  find  in  the  two  types.  It  is  true  that 
so  distinguished  a histologist  as  Ramon  y Cajal  declared  in  the  work 
just  cited  that  the  microscopic  sections  of  the  various  sensory,  motor, 
and  associative  zones  of  the  cerebral  cortex  can  be  distinguished  at  a 
glance  of  the  eye.  It  is  true,  also,  that  the  most  recent  researches 
of  the  same  Cajal,  of  Hammarberg  {Studien  ueher  Klinik  und 
Pathologie  der  Idiotie,  Upsala,  1895),  and  of  Schlapp  {Der  Zellen- 
hau  der  Grosshirnrinde  des  Affen  Macacus  Gynomolgus — Arch.  /. 
Psychiatric,  Bd.  30),  always  tend  to  further  differentiate  the  struc- 
ture of  the  various  cortical  zones.  Apart  from  the  fact,  however, 
that  we  are  very  far  from,  having  a secure  notion  of  the  histological 
differences,  as  Hitzig  justly  mentioned,  drawing  his  argument  from 
the  researches  of  Kolliker  and  Siemerling,  who  have  been  unable  to 
confirm  the  existence  of  morphological  differences  between  the 
different  cortical  territories,  it  is  simply  arbitrary  to  assign  to  those 
structural  dissimilarities  difference  in  function  in  the  sense  of 
Flechsig,  who  attributes  a higher  intellectual  value  to  the  posterior 
associative  zone.  Such  a conception  is  disproved,  also,  by  another 
fact — viz.,  by  the  marked  demxntia  found  in  individuals  suffering 
from  word-deafness  due  to  a destructive  focus  in  the  first  temporal 
convolution.  As  is  known,  this  part  of  the  zone  of  language  is 
included  in  the  limits  of  the  auditory  or  perceptive  sensory  area 
by  the  same  Flechsig  (prim.ordial  territory.  No.  7,  and  in  part  of 
the  intermiediate  territory.  No.  23).  It  is  impossible  on  the  known 
facts  to  assign  distinct  areas  to  the  function  of  generic  audition  and 
that  of  verbal  audition  in  particular.  It  appears,  rather,  that  the 
two  functions  are  located  in  the  same  area,  with  marked  predomi- 
nance, on  the  left  side,  of  the  specihc  function  of  language  (audition 
and  registration  of  words  spoken  by  others)  as  compared  with  the 
general  function  of  hearing. 

In  this  case  we  find  a specific  function  of  high  intellectual  value, 
located  in  the  primordial  and  intermediate  area,  and  it  is  easy  to 
understand  which  and  how  many  psychic  and  sensory  components 
enter  into  the  formation  of  the  acoustic  verbal  images,  which 
synthetize  not  only  the  auditory  or  phonic  components  of  speech, 
but  also  the  numerous  and  complex  series  of  visual,  tactile,  and 
muscular  images,  and  those  of  all  the  other  senses,  in  so  far  as  they 
refer  to  the  object  portrayed  and  made  capable  of  recognition  in 
all  its  attributes  by  the  word.  In  my  opinion  few  regions  of  the 
cerebral  mantle  have  such  numerous  and  extensive  relations  with 
the  rest  of  the  brain,  and  are  so  intim-ately  bound  up  with  the  forma- 
tion of  thought  and  with  all  the  workings  of  the  mind,  as  the  first 


ASSOCIATIVE  NATURE  OF  MOTOR  ZONE 


157 


temporal  convolution  on  the  left  side.  In  this  region  the  thoughts 
assume  their  moulded  form  in  speech,  which  tends  always  to  portray 
more  clearly  the  individual  components  and  their  synthesis,  besides 
all  the  changes  which  occur  from  the  incessant  alternation  of  number- 
less external  and  internal  stimuli.  This  region,  however,  is  repre- 
sented by  Flechsig  as  a primordial  and  intermediate  perceptive  zone, 
and  thus  would  have,  according  to  the  fundamental  condition  of 
, this  author,  less  importance  than  his  great  parieto-occipital  associa- 
tive zone. 

The  fact,  which  I have  very  frequently  noted  {II  Policlinico, 
1894),  of  the  existence  of  marked  dementia  associated  with  word- 
deafness  does  not  go  in  favour  of  the  above  hypothesis,  which  in 
these  cases  is  upheld  only  by  the  impossibility  of  associating  in  the 
cortex  the  sensory  impressions  acquired  through  the  hearing,  and 
points  therefore  to  a disturbance  of  the  faculty  of  co-ordination  ; 
on  the  contrary,  in  my  opinion,  it  is  dependent  on  a true  loss  of 
image-records,  of  which  each  sensory  and  perceptive  area  is  creative 
and  preservative.  We  do  not  agree  with  the  hypothesis  of  those, 
among  whom  is  Hitzig,  who  regard  the  cerebral  mantle  as  the  organ 
of  consciousness,  and  consider  that  the  images  are  formed  in  the 
subcortical  ganglia,  becoming  conscious  when  they  are  projected 
upon  the  cerebral  cortex — that  is  to  say,  upon  the  consciousness. 
To  my  thinking,  the  subcortical  ganglia  merely  prepare  the  nerve 
wave,  which  comes  to  them  from  the  periphery,  or  any  of  the  com- 
ponents, for  the  formation  of  the  image,  which  is  ultimately  per- 
fected in  the  cortex  only,  either  by  the  intrinsic  mechanism  of  the 
more  perfect  anatomical  constituents  of  the  cortex  or  by  the  possi- 
bility of  different  psycho-physiological  components  meeting  with 
one  another,  and  hence  giving  rise  to  physiological  fusion,  rendered 
possible  by  the  relations  subsisting  between  the  histological  com- 
ponents. The  state  of  consciousness  is  in  proportion  to  the  number 
of  histological  components  with  which  the  image,  formed  in  the 
cortex,  enters  into  relation. 

We  come  now  to  the  motor  zone.  In  so  far  as  one  wishes  to  con- 
sider it  a zone  of  projection  it  is  easy  to  understand  that  there  should 
arrive  at  it  all  the  nerve  waves  from,  the  various  sensory  zones  and 
from  the  somaesthetic  zone  itself,  which — unless  we  accept  the  ideas 
of  Hitzig  and  Flechsig,  who  regard  the  motor  zone  as  sensory  (tactile 
zone),  that  is  to  say,  a cortical  zone  of  projection  of  the  move- 
ments completed — if  it  does  not  coincide  exactly  with  the  motor  zone, 
at  least  surrounds  it  in  part.  Such  anatomical  connections  render 
possible  the  reactive  relations  with  the  external  world.  It  is  to  the 
cortex  of  the  brain  what  the  anterior  cornua  of  the  spinal  medulla 
are  to  the  sensory  paths,  or  rather  to  the  posterior  cornua  ; what  the 
gray  motor  masses  of  the  corpora  quadrigemina  are  to  the  nuclei 
of  origin  of  the  acoustic  nerves  and  to  the  optic  paths.  In  each  case 


158 


PSYCHIATRY 


centripetal  waves  traverse  the  motor  centres,  and  then  exert  their 
influence  on  the  muscular  apparatus.  There  vary  only  the  grade, 
the  worth,  and  the  number  of  the  components  ; the  function  is  the 
same,  and  it  is  governed  by  the  universal  law  of  the  reflexes.  In 
proportion  as  we  ascend  in  the  spinal  medulla  the  reflexes  assume 
features  of  greater  complexity,  on  account  of  the  fact  that  a greater 
number  of  factors  enter  into  its  production,  till  it  becomes  a con- 
scious psychic  fact  of  the  highest  value. 

In  order  that  the  reflex  may  occur  it  is  necessary  that  all  the 
products  resulting  in  the  individual  zones  of  the  cerebral  cortex 
act  upon  the  motor  zone.  In  this  way  it  reflects  on  the  external 
world  the  number  and  character  of  the  psycho-sensory  products 
which  excite  it,  singly  or  in  association.  In  consequence  of  our  per- 
ceptions we  execute  quite  an  infinite  series  of  movements— move- 
ments of  approximation  and  movements  of  withdrawal,  according 
as  the  object  causing  the  movement  gives  rise  to  pleasure  or  pain. 

If  this  is  the  functional  mechanism,  the  so-called  motor  zone  can 
only  be  an  associative  zone,  and  this  more  so  than  the  large  postero- 
inferior  associative  zone  of  Flechsig,  because  it  utilizes  the  product 
of  all  the  sensory  zones  situated  behind  and  below.  It  is  always 
the  first  to  be  myelinated,  and  is  identified  with  the  No.  i of 
Flechsig’s  scheme.  Evidently,  the  fibres  which  are  first  myelinated 
are  only  a small  portion  of  those  which  arrive  at  the  motor  zone,  and 
if,  in  course  of  development,  many  others  reach  it  from  all  parts  of  ; 
the  brain,  what  value  remains  in  the  distinction  between  zone  of  : 
projection  and  associative  zone  ? 

In  front  of  the  motor  zone,  as  though  forming  part  of  it,  is  another,  ^ 
embracing  the  base  of  the  frontal  convolutions,  which,  according  to  | 
almost  all  authorities  (from  Boyer  and  Pitres  onwards),  forms  an 
integral  part  of  the  motor  zone.  In  my  opinion  it  is  an  area  of 
evolution  of  the  motor  zone,  and,  if  we  accept  the  observations  so 
far  made,  the  middle  part  of  this  strip  becomes  the  field  of  extension.  : 
of  the  motor  zone  of  the  upper  limb  for  the  complex  movements  j 
involved  in  special  occupations — e.g.,  writing.  In  fact,  a new.  ^ 
intense,  and  prolonged  work  must  induce  not  only  a perfecting  of  ^ 
the  primitive  function,  but  also  a greater  extension  of  the  functioning  > 
surface  of  the  cortex.  Notwithstanding  all  the  doubts  expressed, 
especially  by  Dejerine  and  Mirallie  iU Aphasie  Sensorielle,  Paris, 
1896),  concerning  the  existence  of  a centre  for  writing,  there  stands 
the  very  probable  fact  that  writing,  exercised  for  a long  time— I would 
say  automatism  in  writing  with  the  right  hand — must  develop  a. 
centre  or  cortical  area  adapted  for  a particular  co-ordination  of 
movements,  distinct  from  the  centre  of  the  more  common  move- 
ments of  the  upper  limb — viz.,  those  of  prehension,  acts  of  defence, 
and  the  coarser  handicrafts  directed  towards  self-preservation. 

As  much  may  be  said  of  the  base  of  the  third  frontal  convolution 
(apart  from  the  difference  in  function  between  the  two  hemispheres'. 


ASSOCIATIVE  NATURE  OF  MOTOR  ZOEE 


159 


in  this  matter),  which  is  the  motor  zone  of  spoken  language,  and  is 
situated  immediately  in  front  of  the  motor  zone  for  movements  of  an 
inferior  order — viz.,  those  of  the  lips,  face,  tongue,  larynx,  etc. — 
in  fact,  of  those  same  muscular  groups  that  are  concerned  in  the 
articulation  of  speech.  I advance  the  hypothesis  that  the  centre 
of  writing,  about  which  there  are  so  many  controversies,  is  to  that 
of  the  movements  of  the  arm  (for  prehension  and  defence)  as  the 
centre  of  articulate  speech  is  to  those  of  mastication,  phonation, 
facial  movement,  etc.,  and  it  is  probable  that  it  is  in  process  of  for- 
mation, because  man,  in  general,  has  been  writing  for  a short  time 
as  compared  with  the  long  time  he  has  used  speech,  with  the  result 
that  the  centre  of  spoken  language  is  more  organized  and  fixed  than 
that  of  written  language. 

The  motor  centres  of  written  and  spoken  language  are  the  seats 
of  a motor  function  which  is  more  intellectual  than  that  of  the 
centres  of  the  muscles  concerned  in  these  particular  functions, 
and  must  be  composed  of  cerebral  units,  which  mould,  by  means  of 
innumerable  associative  paths,  various  products  of  near  and 
distant  neurones,  all  contributing  to  a high  function,  which,  though 
fundamentally  motor,  is  in  reality  the  most  genuine  expression  of 
the  intellect. 

It  is  quite  clear  that  the  areas  of  which  we  have  been  treating 
must,  of  necessity,  be  associative  and  of  the  highest  value,  owing  to 
the  numerous  relations  they  have  with  other  parts  of  the  brain, 
although,  by  the  majority  of  authorities,  they  have  been  comprised 
in  the  motor,  tactile,  or  projection  zone  (from  Boyer  to  Pitres,  from 
Luciani  to  Flechsig).  The  relation  between  myelination,  function,, 
and  rank  would  lead  to  the  conclusion  that  there  exists  a certain 
order  of  functional  development  which  coincides  with  the  develop- 
ment of  the  myelination  of  the  submantellar  white  substance.  The 
parallelism,  however,  does  not  hold  good,  but,  on  the  contrary,  con- 
flicts with  the  most  assured  facts  of  the  physiology  of  the  mantle. 
Monakow  and  the  consorts  Vogt  have  already  observed  that  it  is 
impossible  to  formulate  any  law  concerning  the  progressive  steps  in 
myelination,  either  per  se  or  in  relation  to  the  development  of  the 
functions.  Hitzig  has  adopted  the  observation  of  Monakow.  It 
would  be  quite  sufficient  to  consider  the  fact  that,  in  the  infant, 
the  volitional  movements  for  walking  are  fulfilled  by  zone  No.  i, 
which  is  the  first  to  develop,  while  the  act  of  walking  and  even 
simpler  volitional  movements  are  much  later  in  development  than 
the  audition  of  language,  which  is  fulfilled  by  the  areas  7 and  23. 

This  numerical  distribution  of  areas  is  not  supported  by  con- 
sentient histological  observations,  nor  is  it  probable,  when  we  con- 
sider the  proximity  of  numbers  so  different  ; and  again,  it  does 
not  support  any  of  the  physiological  facts  less  disputed.  The  un- 
prejudiced examination  of  the  facts  and  the  very  story  of  the  evolu- 
tion of  the  cerebral  mantle,  from  the  point  of  view  of  its  function. 


i6o 


PSYCHIATRY 


leads  to  the  idea  that  the  architectural  plan  upon  which  the  brain 
has  been  developed  exhibits  a postero-anterior  direction.  The 
visual  area,  from  the  occipital  pole  to  its  extreme  anterior  boun- 
daries with  the  somsesthetic  zone,  increases  in  functional  value 
from  the  preponderant  sensitiveness  to  light  which  is  found  at  the 
pole  to  the  preponderant  perception  of  objects  seen  which  occurs 
in  the  external  occipito-parietal  region  ; and,  becoming  further 
differentiated  and  exalted  through  the  most  recent  and  more  intense 
work  of  modern  man,  it  forms  the  seat  of  the  visual  graphic  function 
at  its  extreme  anterior  limit. 

In  like  manner,  the  motor  and  somaesthetic  zone,  extending 
forwards  to  the  base  of  the  second  and  third  frontal  convolution, 
assumes  a functional  value  very  much  superior  to  that  of  the  part  of 
the  motor  zone  concerned  in  the  movements  of  the  muscular  regions 
of  the  face,  tongue,  pharynx,  larynx,  and  of  the  limbs,  which  are 
severally  brought  into  pla-y  by  mastication,  deglutition,  respira- 
tion, shouting,  prehension,  etc.  Precisely  the  same  muscles  are 
called  into  play  in  such  high  motor  functions  as  spoken  language, 
residing  in  the  foot  of  the  third,  and  writing,  in  the  foot  of  the 
second,  frontal  convolutions,  in  proximity  to  the  cortical  areas  of 
the  same  muscles.  From  this  it  still  appears  clear  that  speech  is  a 
function  of  the  motor  or  senso-motor  zone  (intermediate  territories), 
while  in  fact  this  zone  is  an  associative  one  of  very  high  value,  pro- 
portionately to  the  immense  number  of  sensory  and  motor  com- 
ponents which  directly  take  part  in  the  function  of  that  part  of  the 
cerebral  mantle. 

I formulate  the  hypothesis  that,  as  the  anterior  ‘ part  of  the 
visual  zone  represents  a zone  of  evolution  of  a much  higher  degree  than 
the  rest  of  the  same  zone  situated  posteriorly,  so  the  pre-Rolandic 
area,  considered  as  a part  of  the  senso-motor  or  somaesthetic  zone, 
may  be  only  an  evolutive  motor  zone  in  the  sense  that  it  represents 
the  field  of  the  outward  manifestation  of  the  higher  and  more  in- 
tellectual motor  activities  displayed  by  the  most  highly  developed 
men. 

By  writing  we  call  into  pls-y  the  same  limbs  and  the  same  muscles 
as  in  the  more  elementary  and  coarser  movements  occurring  in  the 
multiform  needs  of  life.  The  more  elementary  movements  of  the 
upper  limbs  are  those  by  which  we  grasp  something  which  appeals 
to  our  bodily  needs  and  satisfies  our  individual  instincts. 

The  evolved  man  no  longer  uses  his  arm  for  preservation  and 
defence  alone,  but  for  numberless  crafts  as  well,  and,  above  all,  to 
express  in  writing  his  own  thoughts  and  emotions  in  his  social  re- 
lations— that  is  to  say,  that  the  motor  zone  in  inferior  beings  and 
also  in  people  of  less  developed  races  presides  over  the  movements 
of  self-preservation  and  self-defence,  and  that,  when  through  civiliza- 
tion man  has  attained  to  that  sublimity  of  thought  that  exists 
to-day  as  compared  with  past  ages,  and  has  acquired  a wealth  of 


ASSOCIATIVE  NATURE  OF  MOTOR  ZONE 


i6i 


language  by  virtue  of  which  the  emotions  and  individual  accom- 
plishments become  common  property  through  the  medium  of  graphic 
symbols,  there  must  be  formed  in  this  same  motor  zone  for  the 
upper  limbs  a special  co-ordination  for  writing.  Are  such  move- 
ments for  writing  formed  by  momentary  associations  (according  to 
the  doctrine  of  Dejerine)  with  those  same  motor  elements  in  the 
central  part  of  the  first  Rolandic  convolution,  or  do  they  emanate 
from  another  specialized  anatomical  territory  ? Those  who  deny 
the  existence  of  a graphic  centre  draw  their  arguments  from  the  fact 
that  we  write  also  with  the  left  hand.  If  there  were  a centre  for 
writing,  the  function  could  not  be  displaceable.  Writing  with  the 
left  hand,  and  in  a sort  of  way  also  with  the  feet,  permits  us  to  infer 
with  Dejerine  that  there  does  not  exist  a special  centre  for  writing. 
But  I would  observe  that  the  formation  of  single  graphic  signs, 
which  can  be  executed  with  the  feet,  even  although  we  may  not  be 
accustomed  to  it,  is  one  thing,  the  automatism  with  which  we 
usually  write  with  the  right  hand  is  quite  another,  seeing  that  the 
automatism  presupposes  a series  of  senso-motor  images  already 
formed  in  a given  part  of  the  brain,  exercised  for  a long  time  and  in 
an  identical  manner. 

Such  automatism  is  quite  indispensable  for  rapidity  and  accuracy 
in  writing. 

It  is  one  thing  to  write  a few  bad  scrawls,  another  to  fill  sheets 
swiftly  and  accurately.  In  other  words,  just  as  in  the  zone  which 
presides  over  the  movements  of  the  upper  limb  a special  centre 
must  be  formed  to  permit  the  special  function  in  the  case  of  the 
pianist  and  the  violinist,  so  specific  sensory  zones  have  been  de- 
veloping for  language  and  music.  The  existence,  then,  of  a centre 
for  writing  is  more  than  probable. 

I admit,  however,  that  it  is  possible  to  have  a different  topo- 
graphy in  individual  instances,  and  that  it  is  possible  to  have  a 
formation  also  in  the  right  hemisphere,  as  in  the  left-handed  and  the 
ambidextrous  ; but  it  is  advantageous  to  agree  that  a new  function, 
as  it  becomes  exercised,  requires  a distinct  anatomical  field.  If  all 
this  be  true,  we  encounter  a new  difficulty  by  accepting  Flechsig’s 
scheme.  The  passage  from  No.  i,  which  is  the  common  motor  zone 
for  the  upper  limb,  to  No.  i6  on  the  foot  of  the  second  frontal  con- 
volution (the  presumed  centre  of  writing),  while  it  shows  a higher 
state  of  evolution  of  this  part  with  respect  to  the  motor  zone  situated 
behind,  represents  a jump  in  the  process  of  myelination  hard  to 
understand,  and  it  conflicts  with  the  supposition  that  territory 
No.  i6  may  be  the  centre  for  writing,  as  this  is  much  later  to 
develop  than  spoken  language,  whose  territory  is  indicated  as  No.  23. 

If  we  bear  in  mind  what  I have  already  said,  that  man  has  been 
speaking  for  thousands  of  years  and  writing  for  only  a short  period, 
and  consider  in  what  enormous  proportion  literary,  scientific,  and 
epistolary  productions  have  increased  in  the  last  century  relatively 

II 


i62 


PSYCHIATRY 


to  the  same  productions  of  the  generality  of  men  in  previous  cen- 
turies, everyone  will  be  convinced  that  a centre  for  writing  alone  can 
be  well  developed  in  but  few  men,  while  in  the  majority  of  man- 
kind it  is  only  in  the  course  of  evolution.  It  is  natural,  then,  that 
many  lesions  of  this  zone  which  might  have  given  rise  to  agraphia 
remain  latent  because  the  function  is  not  yet  developed  like  that  of 
spoken  language. 

The  brain  is  in  a state  of  continual  evolution.  Therein,  if  I am  I 
not  mistaken,  we  must  recognise  one  of  the  phenomena  of  human  i 
progress — the  substitution,  in  the  course  of  the  perennial  evolu- 
tionary process,  of  movements  expressed  in  speech  and  writing  for 
those  coarser  and  simpler  ones  with  which  primitive  man  reacted  in 
obedience  to  his  emotions  and  perceptions.  The  highest  mental 
perfecting  consists  in  condensing  in  speech  all  the  vast  capital  of 
the  understanding,  reacting  on  the  world  not  only  with  individual 
movements,  but  also  with  those  which  serve  to  blend  the  thought 
and  action  of  the  individual  with  those  of  the  community,  of  which 
the  highest  expression  is  precisely  spoken  and  WTitten  language. 

Corresponding  to  this  psychological  phenomenon  there  is  formed 
in  front  of  the  motor  zone  an  area  with  a motor  function  which  is 
more  intellectual,  representing  a stage  of  higher  evolution  and 
cortical  perfecting,  given  up  to  the  delicate  function  of  expressing 
the  emotions,  volitions,  and  thoughts  in  spoken  and  written  language.  - 
The  motor  zone  of  language,  however,  is  included  in  the  zone  of  ; 
senso-motor  projection  in  Flechsig’s  original  works,  among  the  : 
intermediate  regions  of  the  mantle  in  his  later  publications  ; but  i 
it  yields  a product  which,  by  its  complexity,  can  only  be  the  result  ^ 
of  associative  labour,  and  from  the  intellectual  point  of  view  such  « 
zone  is  a long  way  superior  to  the  great  posterior  associative  zone 
of  Flechsig.  For  that  matter,  no  advantage  is  derived  from  the 
distinction  drawn  between  the  zone  of  projection  and  the  associative 
zone  save  the  anatomical  fact,  which  can  only  have  a scanty  and  ’ 
limited  application  in  psychology  as  well  as  in  mental  pathology.  | 

I 

We  pass  now  to  the  anterior  associative  area  of  Flechsig — the  j 
frontal  lobe.  In  many  species  of  animals  it  is  entirely  absent  ; no  | 
trace  of  it  is  found  in  the  batrachians  and  the  amphibians.  In  birds 
we  perceive  a bare  rudiment  of  it,  and  thence  it  proceeds  through 
a constant  evolution,  becoming  differentiated  and  increasing  in 
volume  in  the  mammals.  However,  even  in  the  more  evolved 
mammals,  as  in  the  dog,  it  is  represented  by  a very  small  part  of 
the  mantle,  almost  a rudiment  of  what  is  found  in  the  monkey  and 
then  in  man,  in  whom  it  reaches  a truly  surprising  development  in 
comparison  with  the  extent  of  all  the  remaining  cerebral  cortex. 

What  part  does  the  frontal  lobe  play  in  the  functional 
mechanism  of  the  brain  ? It  is  not  a motor  centre  : it  is  not 
even  a centre  for  sensation  ; that  is  now  universally  recognised. 


PHYSIOLOGY  OF  THE  FRONTAL  LOBES  163 

more  so  after  the  experimental  demonstration  I have  given  of  this 
fact  (Bianchi,  ‘ The  Functions  of  the  Frontal  Lobe,’  Brain,  1895). 
It  can  be  destroyed  up  to  the  prefrontal  sulcus,  as  happens  in 
some  cases  of  disease,  or  as  may  be  experimentally  produced  in 
the  monkey.  In  the  latter  case,  after  the  lapse  of  a few  days,  we 
find  neither  disturbances  of  motion  nor  of  sensation.  While  all 
the  other  cortical  areas  are  sensory  or  senso-motor  and  correspond 
directly  or  indirectly  with  the  special  senses  or  with  the  various 
muscular  regions,  or  are  the  seat  of  more  complex  psychic  formations 
of  each  kind  of  special  sensation,  the  frontal  lobe  has  functions 
which  have  regard  to  the  entirety  of  the  psychic  personality. 
Bilateral  destruction  of  it  gives  only  obvious  mental  disturbances. 

My  idea  is  that  the  frontal  lobe  is  the  organ  of  the  physiological 
fusion  of  all  the  sensory  and  motor  products  elaborated  in  the 
regions  of  the  cortex,  respectively  the  seats  of  special  sensory  and 
motor  functions  ; it  is  the  organ  of  the  synthesis,  present  and  past, 
of  the  two  great  components  of  the  mind,  the  somatic-emotive  and 
the'intellectual  or  cognitive. 

It  is  certain  that  associative  connections  exist  between  the 
various  sensory  zones,  and  hence  between  the  products  elaborated 
by  the  perceptive  and  senso-motor  areas.  But  the  field  in  which 
we  meet  with  the  greatest  disposable  number  of  commemorative 
images,  whose  representation  in  the  consciousness  is  a condition  of 
judgment,  is,  according  to  experimental  and  clinical  data,  the 
frontal  lobe. 

The  concrete  images  are  synthetized  in  man  in  conceptions  or 
abstractions.  The  conceptions  are  nothing  else  than  the  product 
of  the  synthesis  of  a number  of  sensory  and  motor  components 
and  their  derivatives,  elaborated  in  the  perceptive  and  the  motor 
areas  of  the  cortex,  and  moulded  into  symbolic  forms  in  the  zone  of 
language.  When,  e.g.,  we  say  ‘ religion,’  we  express  a very  com- 
plex conception,  which,  in  the  illiterate,  will  consist  of  a few  concrete 
images — a church,  some  priest,  some  sacred  picture — and  a sum  of 
mixed  sentiments,  with  a preponderance  of  awe  and  veneration, 
while  in  the  cultured  man  it  contains  in  synthesis  an  infinity  of 
images,  notions,  and  emotions  referring  to  the  central  conception, 
like  the  atoms  forming  the  protagon  of  the  nervous  substance. 
All  these  numerous  series  of  auditory  images  (sounds,  intonations, 
and  prayers)  or  of  emotions  (from  the  fear  of  the  inferno  to  the 
highest  and  noblest  moral  sentiments),  and  all  the  notions  regarding 
the  literature  of  religions,  their  origins  and  transformations — al] 
these  components,  moulded  in  the  appropriate  words,  sustained  in 
^heii  turn  by  an  infinity  of  other  simpler  components,  become 
synthetized  by  psychic  affinity  into  one  psychic  product  which  we 
call  a conception,  and  which  also  becomes  expressed  in  a single 
vvord.  This  process  of  psychic  synthesis,  raising  the  personality 
ind  the  consciousness  above  the  purely  sensory  field,  is  the  principal 

II — 2 


i64  psychiatry 

function  of  the  frontal  lobes.  The  majority  of  clinical  cases,  which 
are  daily  increasing  in  number,  show  very  clearly  the  power  of 
synthesis  and  cohesion  of  perceptions  that  is  possessed  by  the 
frontal  lobes.  Persons  seriously  injured  in  this  region  of  the  brain 
perceive  through  the  individual  senses  the  impressions  of  the 
external  world,  and  react  to  the  individual  sensation  with  com- 
paratively well-adapted  movements.  They  are  defective,  however, 
in  the  power  of  reawakening  and  associating  the  images  from  whose 
union  result  more  accurate  and  complex  judgments,  and  of  forming 
intellectual  syntheses  of  a higher  order.  I quote  an  example  from 
the  large  number  of  entries  in  the  register  of  my  experiments.  To 
a monkey  with  brain  intact  I give  a piece  of  chalk  cut  like  a cube  , 
of  sugar,  of  which  it  is  very  fond.  On  seeing  it  he  grasps  it,  ex- 
amines it,  smells  it,  handles  it  all  ways,  tastes  it  very  cautiously, 
and  finally  throws  it  away.  He  takes  it  up  again,  disappointed 
in  not  being  able  to  satisfy  his  desire  to  eat  it,  re-examines  it,  and 
rejects  it  entirely.  If  afterwards  I present  him  with  a piece  of  real 
sugar,  of  the  same  form  and  colour,  he  immediately  recognises  it, 
but,  recollecting  the  former  piece,  which  it  resembles,  first  tastes 
it  and  then  suddenly  eats  it  with  great  gusto.  The  refusal  of  the  ! 
first  piece  is  the  result  of  a judgment  based  on  the  representation  I 
of  the  tactile,  visual,  muscular,  olfactory,  and  gustatory  images  | 
of  the  sugar  contrasted  with  the  analogous  images  of  the  piece  of  : 
chalk.  Here  we  perceive  a re-evocative  and  associative  power, 
through  the  recognition  of  the  objects  present.  If  the  frontal  lobes  | 
of  such  a monkey  be  removed  and  the  experiment  then  repeated,  I 
it  will  be  seen  that  all  the  monkey  has  lost  is  the  power  of  re-evoking  - 
analogous  images  in  order  to  synthetize  them  into  the  concretejj 
image  of  the  objects  producing  the  actual  sensation.  This  is  j 
deduced  from  the  observation  that  the  monkey  quickly  puts  out 
his  hands  to  obtain  the  piece  of  chalk,  but  does  not  examine  it  nor 
judge  it  as  he  did  previous  to  the  operation  ; instead,  he  puts  it'| 
into  his  mouth,  masticates  it,  grinds  it,  remains  for  a time  uncertain  i; 
whether  or  not  to  swallow  it,  and  then  most  frequently  ends  by, 
doing  so.  There  are  thus  preserved  sight,  taste,  and  touch,  which 
give  the  immediate  perception,  and  result  in  movements  adapted 
exactly  as  before  for  prehension ; but  there  is  defective  judgment, 
which  can  only  be  got  by  contrasting  the  images  previously  registered 
with  the  actual  perceptions,  or  at  most  such  contrast  is  so  very 
incomplete  as  not  to  furnish  the  data  for  an  accurate  differential 
judgment.  It  is  not  improbable  that  the  act  of  recognition  causing 
the  now  half-witted  monkey  to  seize  the  piece  of  chalk  and  greedily^ 
carry  it  to  his  mouth  is  the  outcome  of  the  strongest  sensation,! 
which  is  the  visual  one,  of  the  colour  and  form  of  the  object.  The 
appearances  are  quite  similar  to  those  of  the  piece  of  sugar  ; but 
there  is  wanting  the  sum  of  all  the  other  sensory  attributes  necessary; 
for  the  differentiation  of  the  images  by  contrast. 


PHYSIOLOGY  OF  THE  FRONTAL  LOBES 


165 

According  to  this  experiment  the  frontal  lobe  should  be  con- 
sidered the  meeting-ground  of  the  sensory  images  for  discrimination 
between  analogous,  similar,  and  dissimilar  objects,  so  that,  if  this 
function  is  in  abeyance,  the  individual  and  strongest  images  remain, 
and  determine  adapted  movements,  while  the  judgment  is  almost 
always  erroneous — the  more  so  the  more  complex  the  perception 
involved. 

In  several  cases  which  have  come  under  my  observation  of 
individuals  who  had  suffered  a severe  injury  to  the  frontal  lobes 
(among  others  that  of  a young  man  in  whom  a bullet  from  a re- 
volver had  traversed  the  frontal  lobes  obliquely  from  the  pre- 
temporal region  on  the  right  side  to  the  frontal  on  the  left),  the  true, 
outstanding  phenomenon  was  amnesia  with  incapacity  to  form  judg- 
ments requiring  the  presence  of  many  sensory  components.  The 
patient  was  certainly  capable  of  perceiving  and  recognising  objects, 
and  also  of  recollecting  their  names,  but  he  was  unable  voluntarily 
to  direct  his  thought  and  to  re-evoke  the  images  wherewith  to 
sustain  it  for  discriminations  of  the  greatest  complexity  and  the 
process  of  coming  to  a conclusion.  In  this  he  succeeded  only  for 
brief  moments  and  in  simple  things  and  positions,  in  which  also 
he  frequently  wandered,  observing  as  though  his  proper  physical 
I identity  were  lost  in  the  intellectual  vacuity.  What  fails  in  such 
cases  is  the  keyboard,  the  keys  of  which,  when  touched,  provoke 
the  respective  sounds  from  the  strings  allocated  to  them.  The 
mechanism  is  so  reduced,  however,  that  the  strings  touched  from 
without  give  sounds  and  notes  complex  to  a degree  corresponding 
to  the  rapidity  of  execution  ; but  without  the  keyboard  there  is  no 
longer  possible  that  rapid  and  co-ordinated  reproduction  of  tones 
fused  in  the  sweetest  harmony  of  a score. 

Xo  one  can  affirm  that  such  a fusion  of  concrete  images — or  if 
not  fusion,  at  least  their  rapid  succession  and  correlation  by  psychic 
affinity — happens  in  any  other  part  of  the  brain  by  means  of  that 
intricate  reticulum  formed  by  protoplasmic  and  axis-cylinder  pro- 
longations given  off  in  all  directions  from  the  cells  of  the  cortex. 
It  is  a certainty,  however,  that  extirpation  of  the  frontal  lobes, 
without  removing  any  of  the  sensory  and  motor  dominions  of  the 
personality,  renders  it  incapable  of  utilizing  its  own  accumulated 
capital,  deposited  in  the  great  sensory  and  senso-motor  treasuries 
of  the  cerebral  mantle. 

The  frontal  lobes  are  not  only  the  organs  for  the  physiological 
fusion  of  the  perceptions  leading  to  the  formation  of  conceptions, 
and  the  field  of  recall  and  summing  together  of  the  concrete 
'images  employed  in  the  process  of  reaching  conclusion  in  the 
judgments  which  the  ego  is  called  on  to  form  in  the  various  positions 
wherein  one  finds  one’s  self,  in  the  ever-changing  relations  to  the 
external  world,  but  also  the  organs  for  physiological  fusion  of  the 


i66 


PSYCHIATRY 


elementary  sentiments  of  each  individual,  from  which  arise  the 
highest  human  sentiments  characterizing  modern  civilized  man. 
After  mutilation  of  the  frontal  lobes  in  monkeys  we  find  weakened, 
almost  to  the  point  of  disappearance,  the  sentiment  of  maternity, 
the  affection  for  and  responsiveness  to  the  persons  tending  them, 
to  whom  they  were  wont  to  show  strong  attachment  in  all  sorts  of 
ways. 

The  same  family  sentiment,  which  also  possesses  its  evolutional 
history,  shows  itself  more  unstable  and  liable  to  decay  in  individuals 
who  have  a weak  development  of  the  frontal  lobes.  They  are  always 
very  egoistic  and  incapable,  regarded  with  relation  to  the  social 
functions.  The  altruistic  sentiment,  which  passes  the  limits  of  the 
family  and  of  the  country,  and  tends  towards  humanitarianism 
without  regard  to  nationality  or  race,  and  is  always  in  course  of 
evolution,  as  well  as  the  social  tendencies  of  our  times,  which  are  the 
highest  expression  of  sentimentality,  are  only  the  products  of 
physiological  fusion  of  the  individual  emotions  in  a universal  senti- 
ment which  judges  all  at  the  same  value,  and  determines  all  to 
actions  tempered  and  directed  for  the  common  good.  All  this 
disappears  on  destruction  of  the  frontal  lobes. 

Love  (which  I have  found  reduced  to  rudimentary  and  brutal 
expressions  in  monkeys  with  mutilated  frontal  lobes),  in  its  highest 
and  most  spiritual  manifestations,  is  likewise  a very  complex  product, 
the  various  factors  of  which  are  united  by  an  intimate  affinity  the 
result  being  a product  of  an  extremely  high  psychic  value.  There 
is  not  enough  space  to  record  such  factors  as  Ribot,  Mantegazza, 
and  others  have  brought  to  light.  It  is  certain,  however,  that 
with  mutilation  of  the  frontal  lobes  love,  in  the  monkey,  is 
reduced  to  the  most  brutal,  brazen-faced,  and  often  ineffective 
expression. 

The  same  might  be  repeated  of  the  moral  sentiment,  which  is 
evolved  from  the  egoistic  sentiment,  and  is  continually  realizing 
its  fulness  in  social  life.  The  moral  sentiment  consists  essentially 
in  this,  that  the  individual  who,  in  the  struggle  for  existence, 
originally  used  primitive  arms  of  offence  and  defence  against  others 
who  were  contending  with  him  for  the  means  of  subsistence,  and 
competing  with  him  for  the  satisfaction  of  their  personal  instincts, 
now  achieves  the  same  end  by  incorporating  his  egoistic  senti- 
ments with  the  emotions  of  his  fellow-beings — which  is  nothing 
else  than  physiological  fusion  of  the  sentiments  of  the  social  units. 
In  this  manner  he  displays  his  activity  in  a form  of  labour  which, 
while  proving  useful  to  himself,  is  helpful  to  others.  Thus  the  labour 
of  the  truly  evolved  man  resolves  itself  into  individual  and  social 
well-being.  Now,  such  logical  fusion  of  the  personal  emotions 
with  those  of  other  individuals  of  society  (seeing  that  the  modern 
man  cannot  be  considered  as  an  isolated  unit,  but  as  forming  part 
of  the  social  organism)  is  a function  of  the  frontal  lobes.  The 


PHYSIOLOGY  OF  THE  FRONTAL  LOBES 


i.6y 


clinique,  as  also  experimentation,  furnishes  us  with  many  facts  in 
proof  of  this  statement,  because  in  the  majority  of  individuals  who 
have  suffered  an  injury  to,  or  a serious  affection  of,  the  frontal  lobes, 
the  most  frequent  phenomenon  is  profound  change  in  the  moral 
character  of  the  individual,  who  becomes  egoistic,  irascible,  solitaiy, 
impulsive,  and  unsociable.  The  monkey  deprived  of  its  frontal 
lobes  becomes  less  tractable,  as  well  as  impulsive,  unaffectionate, 
and  indifferent  to  the  person  or  the  animals  of  whom  formerly  it 
was  very  fond. 

The  majoritv  of  born  delinquents  have  a defective  develop- 
ment of  the  frontal  lobes,  as  one  can  often  infer  from  an  external 
examination.  They  have  a forehead  low  set,  narrow,  and  receding  ; 
on  the  other  hand,  they  show  strong  development  of  the  jawbones, 
the  frontal  sinuses,  and  the  supra-orbital  crests.  If  among  them 
there  be  one  who  presents  a large  forehead  it  usually  is  identified 
with  an  individual  who  has  suffered  from  hydrocephalus  in  infancy, 
delay  in  ossification  of  the  sutures,  etc. 

The  consciousness  likewise  has  its  anatomical  substratum  in  the 
frontal  lobes.  What  we  call  the  ego,  which  is  cognisant  of  time  and 
space,  is  not  an  invariable  unit,  but  is  even  very  changeable  in  the 
course  of  time — i.e.,  in  the  history  of  the  individual.  It  is  only  in 
part  the  synthetic  representation  of  self,  because  it  partly  reflects 
also  its  environment.  Here  we  always  find  the  same  law  of  evolu- 
tion ; the  consciousness  of  cephalopods  is  one  form  of  consciousness, 
that  of  reptiles  another,  that  of  the  dog  a third,  and  so  forth.  In 
proportion  as  the  anatomical  elements  of  the  cerebral  mantle  in- 
crease in  number  they  contribute  towards  the  formation  of  the 
consciousness,  which  we  can  recognise  in  its  various  stages  of  evolu- 
tion. With  the  histological  elements  the  notions  of  the  external 
world  are  also  virtually  increased  in  number,  and  the  differentiation 
of  the  ego  proceeds  in  proportion  to  the  number  of  notions,  emotions, 
and  reactions. 

The  constant  law  is  that  the  consciousness  perfects  itself 
in  proportion  as  new  and  more  numerous  nervous  elements  are 
called  to  take  part  in  the  work  of  the  cerebral  mantle.  Now,  it  is 
natural  that  the  somatic  consciousness,  in  so  far  as  we  feel  we  are 
living,  and  experience  by  turns  now  the  hurried  pulsing  of  pleasures, 
now  the  raging  violence  of  organic  pains,  real  or  imaginary,  is  only 
a partial  consciousness,  until  there  is  added  to  it  the  consciousness 
of  all  the  individual  perceptions  and  all  the  psychic  compounds 
resulting  from  the  infinite  combinations  of  perceptions.  On  the 
other  hand,  consciousness,  considered  as  the  central  point  of  recog- 
nition of  perceptions,  emotions,  and  reactions,  changes  every 
moment  under  the  influence  of  the  external  stimuli,  which  act  on  our 
senses  in  extraordinary  number,  and  furnish  new  material  for  the 
perceptive  laboratories  and  for  that  of  the  consciousness,  where  the 


i68 


PSYCHIATRY 


old  components  meet  with  those  fresh  ones  coming  every  moment 
from  without. 

Such  consciousness  is  only  a synthesis  on  the  basis  of  a memory 
which  sums  up  the  history  of  the  individual  throughout  each  unit 
of  time,  and  is  referable  to  a given  quality  of  stimulus.  On  the 
other  hand,  the  consciousness  should  be  considered  as  divisible 
into  internal  and  external — the  me  and  mine  ; the  knowledge  we 
have  of  ourselves  embraces  not  merely  what  we  are  as  a complex 
of  notions,  sentiments,  and  actions,  which  have  become  integral 
parts  of  ourselves,  but  likewise  everything  that  appertains  to  us  : 
there  is  an  exterior  zone,  so  to  speak,  of  the  consciousness,  but  one 
which  completes  it.  The  family  members,  those  with  whom  we 
associate,  the  objects  which  belong  to  us,  our  possessions,  the  duties 
to  which  we  apply  ourselves,  the  world  wherein  we  live,  and  from 
which  so  many  sighs  reach  us,  reawakening  emotions  always  alter- 
nating, all  form  a part  of  our  consciousness.  The  second  part  of 
the  consciousness  becomes  synthetized  with  the  first,  but  is  itself 
more  and  more  subject  to  increase  through  culture  and  social  and 
cosmic  relations. 

Let  us  picture  to  ourselves  the  solitary  man.  He  has  certainlv 
a consciousness — somewhat  limited  withal — of  himself,  his  actions, 
his  affairs,  and  the  surroundings  in  which  he  lives.  He  is  very 
different,  however,  from  him  who  lives  in  the  social  atmosphere, 
and  who  feels  a flow  of  energy  coming  to  him  from  his  surround- 
ings, and  a reflux  from  himself  to  the  outer  world.  The  latter  is 
no  longer  a free  unit  in  space  ; he  is  a point  of  afflux  and  reflux  in 
the  great  social  and  cosmic  organism. 

As  in  the  case  of  intelligence,  so  also  in  that  of  consciousness, 
being  the  point  of  synthesis  of  all  the  components  of  the  personality 
and  its  relations  with  the  outer  world,  all  the  cortical  zones  con- 
tiibute  their  quota  to  it.  I am  unable  to  accept  the  opinion  of 
Flechsig,  who  holds  the  tactile  sphere  to  be  the  central  organ  of  our 
intellectual  existence.  The  tactile  sphere  furnishes  at  most  the 
organic  and  emotive  components  of  the  consciousness,  in  the  same 
way  that  the  sensory  sphere  furnishes  the  intellectual  and  organic 
(organic  because  the  perceptions  contain  senso-motor  components)  ; 
but  the  fiontal  lobes  represent  the  field  of  meeting  and  synthesis 
in  both  cases.  In  fact,  those  individuals  who  happen  to  have 
defective  development  of  the  frontal  lobes,  or  have  suffered  a serious 
lesion  thereof,  show  a notable  dispersion  and  reduction  of  the  ego. 
In  the  same  way,  monkeys  deprived  of  their  frontal  lobes  certainly 
show  the  possession  of  a somaesthetic  consciousness,  but  this  is  no 
longei  so  accurate  as  that  resulting  from  the  fusion  of  the  organic 
consciousness  with  the  components  referable  to  the  environment. 
All  the  psychic  components  of  kinship,  love,  friendship,  gratitude, 
and  sociability  disappear,  so  that  the  animals  lead  solitary  and 
indifferent  lives. 


PHYSIOLOGY  OF  THE  FRONTAL  LOBES 


169 


It  is  said  by  some  authorities  that  the  frontal  lobes  might  con- 
stitute the  organ  of  attention.  The  question  is  one  concerned  with 
the  activity  of  the  mind,  of  the  physiology  of  which  much  has  been 
said  and  written.  The  act  of  attention,  whereby  in  a given  unit  of 
time  we  select  from  the  most  various  external  stimuli  that  which 
is  agreeable,  upon  which  we  concentrate  our  faculty  of  observation, 
and  which  we  perceive  better  than  others,  is  a process  undergoing 
many  modifications  in  different  individuals,  and  in  the  same  in- 
dividual at  different  times,  through  external  and  internal  circum- 
stances and  through  pathological  conditions.  Mental  maladies,  or 
the  majority  of  them,  present  a rich  collection  of  qualitative  and 
quantitative  alterations  of  the  attention  up  to  complete  abolition. 
Attention  is  only  a reflex  phenomenon  of  the  ego  in  response  to  the 
stimulus  acting  on  our  senses,  or  the  recent  or  former  image  of  it, 
or  the  more  complex  psychic  products  of  which  one  or  more  images 
are  the  strongest  components  (direct  or  derived  attention).  I 
must  not  dwell  here  upon  the  physiology  of  attention,  but  to  say 
that  the  frontal  lobes  are  the  centres  of  attention  is  to  limit  or 
restrict  the  function  of  the  frontal  lobes  to  a single  phenomenon,  to 
one  component  only  of  the  complicated  mechanism  of  its  activity ; 
for  it  is  evident  that  voluntary  attention  is  only  realized  through 
the  mnemonic  reawakening  of  perceptions  similar,  analogous,  dis- 
similar, contrasting,  and  their  direct  or  derived  compounds,  etc. — 
that  is  to  say,  through  the  synthesis  of  the  perceptions  and 
their  derivatives,  direct  and  indirect.  If  such  synthesis  be 
not  realizable,  a true  process  of  attention  does  not  appear 
possible. 

In  fact,  those  individuals  whose  frontal  lobes  are  undeveloped 
never  present  much  power  of  attention  ; on  the  contrary,  their 
psychic  life  resolves  itself  into  senso-motor  reflexes,  or  they  give 
clear  evidence  of  that  state  of  which  James  says  in  happy  phrase, 
‘ The  foreground  of  consciousness  is  filled,  if  by  anything,  by  a sort 
of  solemn  sense  of  surrender  to  the  empty  passing  of  time.’  By 
extirpating  the  frontal  lobes  we  can  suppress  volitional  attention  in 
those  animals  which  in  the  zoological  scale  present  a more  notable 
development  of  this  faculty — e.g.,  dogs  and  monkeys.  Thus,  also, 
persons  who  have  suffered  an  injury  to  this  region  of  the  brain  show 
a feeble  power  of  attention,  do  not  pause  to  reflect  on  anything,  in 
some  cases  are  bewildered,  in  others  impulsive  or  restless,  distracted 
and  inconsequent  in  their  reasoning.  It  becomes  impossible  for 
them  to  maintain,  connected  and  flowing  through  the  field  of  con- 
sciousness, a great  number  of  psychic  components. 

Attention,  considered  as  a reflex,  is  not  an  exclusive  function 
of  the  frontal  lobes,  but  a phenomenon  emanating  from  the  activity 
of  all  the  sensory  zones  of  the  cortex  ; volitional  attention,  how- 
ever, is  intimately  connected  with  the  function  of  the  intellectual 
and  sentimental  syntheses,  which  induce  strong  states  of  conscious- 


170 


PSYCHIATRY 


ness,  and  it  therefore  appears  weakened,  both  in  man  and  animals, 
by  the  mutilation  above  referred  to. 


It  is  also  held  that  the  frontal  lobes  may  be  the  organ  of  inhi- 
bition. It  is  well  to  be  agreed  on  the  definition  of  inhibition, 
because  it  will  be  impossible  to  understand  anything  of  it  unless  by 
admitting  a dynamism  whose  field  of  action  may  vary  in  the  different 
provinces  of  the  central  nervous  system.  We  put  aside  both  the 
physical  theory  of  interference  (Cyon  and  Lauder  Brunton)  and 
the  chemical  theory  of  assimilation  as  applied  to  the  phenomena  of 
inhibition.  The  simplest  fact  is  the  inhibitory  influence  which  the 
brain  exercises  on  the  spinal  cord.  When  an  animal  is  deprived  of 
its  brain  (it  may  be  a frog  or  even  a mammal,  for  it  is  seen  that  even 
mammals  of  the  higher  orders  can  stand  extirpation  of  the  whole 
cerebral  mantle — Goltz — and  survive  the  operation),  and  is  then 
excited,  the  spinal  reflexes  are  found  to  be  exaggerated,  and  the 
reaction  to  the  stim^ulus  occurs  in  a shorter  time  than  in  the  normal 
condition  (Schiff,  Oddi,  Landois,  Fano,  Libertini).  When,  on  the 
other  hand,  the  cerebral  mantle  is  acting,  the  reaction  time  is  longer 
and  the  extent  of  the  movement  is  less.  This  fact  of  the  diminution 
of  the  time  and  augmentation  of  the  reflex,  consequent  upon  the 
abolition  of  the  function  of  a more  evolved  central  organ,  is  an 
expression  of  the  inhibitory  influence  which  one  nerve  centre  exer- 
cises upon  another.  It  seems  to  me  almost  impossible  to  consider 
the  inhibitory  power  as  a specific  function  which  may  be  exercised 
by  certain  particular  organs  upon  certain  others.  Such  a concep- 
tion is  bound  to  disappear  from  the  physiology  of  the  nerve  centres. 
I go  upon  the  principle,  founded  on  observation  of  facts,  that  every 
nerve  organ,  particularly  of  the  cerebral  mantle,  can  in  its  turn  be 
a centre  of  inhibition  and  an  inhibited  organ  at  different  times  and 
under  varying  circumstances. 


The  experience  of  everyonea  t all  times  will  competently  support 
this  theory.  If  one  of  the  perceptive  centres  is  hyperfunctioning 
under  the  influence  of  adequate  stimuli,  it  becomes,  by  the  very  fact 
of  the  increase  in  activity,  a centre  of  inhibition  of  the  others  with 
which  it  may  be  in  anatomical  relation.  The  sight  of  a picture 
which  takes  us  by  surprise,  of  a scene  which  pleases  us,  or  the  reading 
of  a page  which  interests  us,  puts  in  hyperfunctional  tension  one  or 
more  cerebral  provinces — let  us  suppose  the  visual  zone  and  the 
frontal  lobes.  If  during  the  work  of  the  visual  region  a slight  noise 
such  as  would  have  been  remarked  in  a state  of  repose  is  made, 
under  these  circumstances  it  passes  unnoticed,  or,  even  if  noticed, 
does  not  become  a perception.  The  auditory  centre  in  such  a case 
is  inhibited  by  the  hyperfunctioning  visual  centre,  and  it  is  then 
unable  to  transform  into  perceptions  the  acoustic  waves  which 
airi\e  theie,  or  to  transmit  the  products  of  its  function  to  other 
provinces  for  further  psychic  combination.  If,  however,  the 


PHYSIOLOGY  OF  THE  FRONTAL  LOBES 


171 

auditory  stimulus  is  very  intense,  it  determines  a hyperfunctional 
state  in  the  organ  of  hearing,  and  then,  under  the  altered  condition, 
the  noise  is  rendered  perceptible  ; but  at  the  same  time  in  which 
this  happens  the  auditory  centre  exercises  an  inhibition  upon  the 
visual  centre.  The  perceptive  intensity  of  the  latter  zone  diminishes 
(inhibition),  and  the  frontal  zone  becomes  more  active  in  another 
direction  and  establishes  closer  relations  with  the  auditory  region, 
whereas  before  it  was  more  engaged  with  the  hyperfunctioning 
visual  zone.  From  these  two  cases  we  see  the  variable  orientation 
of  the  frontal  function,  which  may  superexcite  one  region  of  the 
cerebral  mantle — when  more  direct  and  numerous  functional 
relations  are  established  between  the  frontal  zone  and  this  region — 
and  lower  the  intensity  of  another  with  which  it  comes  into  a less 
close  relation  for  the  time  being.  We  deduce  from  this  that  the 
frontal  lobe  exercises  an  exciting  action  upon  the  perceptive  zones 
with  which  it  has  functional  relations. 

If,  while  walking,  one  is  overwhelmed  by  a thought  which  in- 
volves great  mental  activity,  unconsciously  the  pace  is  slackened  ; 
this  is  an  inhibition  of  walking.  If,  on  the  contrary,  one  is  bent 
on  arriving  somewhere,  and  the  object  of  the  walk  is  vividly  repre- 
sented, the  pace  will  be  rapid  and  brisk  in  proportion  : nothing  else 
crossing  the  threshold  of  consciousness,  be  it  external  or  internal, 
wiU  exercise  a power  of  arrest  on  the  walking  unless  it  be  substi- 
tuted for  the  object  of  the  walk.  Then  only  has  an  extraneous 
thought  the  power  of  slowing  the  pace,  and  even  the  consciousness 
of  the  object  of  the  walk  may  in  given  cases  succeed  in  slowing  or 
arresting  thought. 

A similar  action  of  arrest  of  the  higher  functions  by  the  lower 
is  very  weak,  and  we  cannot  estimate  it  except  in  morbid  states. 
The  more  demonstrable  fact  is  that  the  higher  function  may  exercise 
a directive  and  inhibitory  influence  on  the  lower.  If  the  higher 
value  is  to  be  placed  upon  the  frontal  lobes  of  organizing  and  syn- 
thetizing  the  intellectual  and  emotional  products  of  the  work  of 
all  the  other  parts  of  the  cerebral  cortex,  they  must  be  retained  as 
the  inhibitory  organ  par  excellence  of  the  other  parts  of  the  same 
brain  with  which  it  has  direct  and  indirect  functional  relations. 
Much  of  the  nervous  dynamism  is  explained  by.  the  numerous 
interlockings  occurring  in  such  a complex  mechanism  as  that  of  the 
frontal  lobes,  compared  with  the  other  cerebral  provinces,  on  which, 
however,  under  the  influence  of  external  or  internal  stimuli,  it  exer- 
cises a stimulating  effect.  The  nervous  activity  is  the  same  all 
over.  There  is  not  a separate  apparatus  for  inhibition  (on  which 
Munk,  Duval,  Luchsinger,  and  Haidenhain  are  agreed),  and  we 
cannot,  like  Oddi,  restrict  the  phenomenon  of  inhibition  within  the 
common  doctrine  of  the  cerebral  localizations.  To  say  that  the 
frontal  lobes  are  set  apart  for  inhibition  is  to  substitute  a corollary 
for  the  whole  chain  of  reasoning. 


172 


PSYCHIATRY 


In  concluding  this  first  part  of  the  work,  one  can  symbolize  the 
cerebral  mantle  as  a state  with  a representative  system — a parlia- 
ment and  government.  The  mantellar  parliament  would  be  con- 
stituted by  the  perceptive  zones,  each  of  which  furnishes  to  the 
central  government  the  product  of  its  own  labour,  accomplished 
with  material  prepared  by  the  force  of  Nature  from  the  primary 
receptive  and  ganglionic  neurones  throughout  the  course  of  successive 
years.  The  central  government  would  be  represented  by  the  frontal 
lobes,  which,  utilizing  the  products  elaborated  by  all  the  members 
of  parliament,  direct  in  their  turn  the  legislative  work  to  the  ad- 
vantage of  the  people,  who  in  the  nervous  system  are  represented 
by  all  those  millions  of  neurones,  scattered  or  grouped  together  in 
the  sensory  periphery  of  the  body,  in  the  ganglia,  in  the  spinal 
medulla,  in  the  posterior,  mid,  and  intermediate  brain,  their  pro- 
ducts being  transmitted  to  the  perceptive  centres,  which  merely 
transform  them  and  transmit  them  in  their  turn  to  the  government, 
whose  synthetic,  directive,  and  regulative  influence  displays  itself 
in  the  adaptation  of  the  individual  to  the  new  conditions  of 
existence,  and  in  the  extension  of  the  individual  and  social 
environment. 

The  primary  neurones  labour  without  the  consciousness,  and 
have  no  direct  representation  in  the  conscious  field  of  the  per- 
sonality ; but  their  work  is  as  necessary  as  that  of  the  neurones  of 
higher  grade,  because  they  incessantly  furnish  material  for  the 
increase  of  the  intelligence  and  personal  consciousness,  and  are  thus 
their  substratum. 

In  the  same  way  that  obscure  workers  among  the  common 
people  add  their  quota  to  the  life  and  prosperity  of  the  state,  just 
as  those  who,  with  their  efficacious  and  co-ordinated  action,  direct 
the  energies  and  opinions  and  determine  the  efficiency  of  the  par- 
liament and  government,  so  the  lowest  neurones  prepare  the 
materials  that  have  to  serve  for  the  formation  of  the  concrete  images 
in  the  perceptive  zones  which  represent  the  infinite  aspects  of 
Nature.  They  become  synthetized  in  the  individual  and  in  the 
collective  consciousness,  just  as  the  representative  government 
synthetizes  the  notions,  the  desires,  and  the  tendencies  of  the 
representatives  of  the  people,  and  in  its  turn  exercises  the  supreme 
directive  influence  over  the  individual  reactions  upon  the  world. 

Fortunate  is  that  state  whose  representatives  are  the  expression 
of  the  intelligence,  emotions,  requirements,  tendencies,  and  aspira- 
tions of  the  people,  and  whose  government  utilizes,  in  its  policies 
and  decisions,  the  products  elaborated  by  the  members  of  par- 
liament ; and  fortunate  is  that  people  whose  government,  appreciat- 
ing its  character  and  interpreting  its  needs,  knows  how,  with  a happy 
synthesis,  to  utilize  the  labour  of  all  the  active  social  units  in  order 
to  bestow  upon  all  its  beneficent  work.  The  work  of  the  frontal 
lobes,  which  resemble  the  government  in  synthetizing  the  products 


PHYSIOLOGY  OF  THE  FRONTAL  LOBES 


173 


elaborated  by  the  perceptive  centres  and  the  emotions  of  the  in- 
dividual and  of  the  community,  in  the  same  fashion  that  the  sensory 
and  perceptive  areas  synthetize  the  labour  of  the  inferior  neurones, 
supplies  the  secret  of  the  fortunes  of  the  individual  in  his  environ- 
ment, or  of  a race  in  its  international  relations. 

The  motor  zone  converts  the  emotional  and  ideative  impulses 
into  acts,  which  are  determined  either  by  the  demands  of  single 
representatives  of  the  people  and  of  parliamentary  groups,  or  by 
the  deliberations  of  the  government,  resulting  from  the  conscious 
s^mthesis  of  the  work  and  requirements  of  all — that  is  to  say,  putting 
aside  the  metaphor,  by  either  the  sensory  perceptive  zones  or  the 
frontal  lobes.  The  former  exert  their  influence  on  the  motor  centres 
either  by  the  actual  perceptions  or  the  commemorative  images  with 
their  derivatives  and  compounds,  or  by  the  products  of  hallucina- 
tion. The  frontal  lobes,  on  the  other  hand,  put  to  account,  in  the 
process  of  deliberation  and  the  resultant  impulse,  all  the  requisi- 
tions and  products  of  the  other  perceptive  zones,  and  by  contrasting 
them  in  the  history  of  the  consciousness  with  similar  and  analogous 
requisitions,  impede  the  movement  or  impress  on  it  that  direction 
which  is  best  calculated  to  facilitate  the  aim  in  life  of  the  individual, 
considered  as  a social  unit.  Such  deliberative  and  directive  power 
over  the  conduct  is  accordingly  defective  or  wanting  in  monkeys 
after  mutilation  of  the  frontal  lobes,  as  also  in  those  persons  who 
show  defective  development  thereof,  or  have  suffered  from  some- 
what extensive  and  bilateral  lesions  in  that  region. 

The  parallel  is  of  little  account,  though  to  some  this  may  seem  a 
paradox ; but  there  is  much  value  in  the  final  conclusion,  in  which  all 
can  agree — viz.,  that  the  frontal  lobes  are,  in  their  ultimate  analysis, 
the  organs  for  the  direction  of  the  individual  in  the  social  and 
cosmic  environment.  In  the  complex  psychic  activities  of  the 
brain,  the  frontal  lobes,  by  utilizing  the  product  of  labour  of  all 
the  sensory  and  motor  spheres,  fulfil  functions  that  are  eminently 
social. 

I regard  the  following  scheme,  according  to  which  each  sensory 
area  on  the  external  face  of  the  hemisphere  is  represented  in  its 
extent  and  its  functional  gradations,  as  being  more  in  harmony  with 
the  best-established  facts,  experimental  and  clinical.  The  terminal 
embryological  territories  of  Flechsig  are  only  evolutionary  zones, 
and  each  of  these  belongs  to  the  perceptive  held  of  the  respective 
special  sense. 

The  evolution  is  functional  more  than  anatomical,  because  it 
still  remains  to  be  demonstrated  that  the  rnyelination  of  the  fibres 
may  show  differences  in  time,  extent,  and  order  in  the  brain  of  a 
savage  as  compared  with  that  of  a first-class  man  in  civilized  Europe. 
The  problem  assumes  another  aspect  when  one  considers  that  in  a 
relatively  brief  time  the  uncultured  individual  can  greatly  augment 
the  sum  of  his  knowledge  and  extend  immensely  the  action  of  his 


174 


PSYCHIATRY 


intellect  by  virtue  of  an  anatomical  substratum  pre-existent,  though 
not  yet  in  use. 

In  my  opinion  we  are  warranted  in  admitting,  on  the  basis  of 
clinical  and  experimental  observations,  only  one  area  that  is  not 
really  in  direct  connection  with  either  the  organs  of  sense  or  those 
of  motion,  and  that  is  the  frontal  lobe.  The  scheme  shows,  also, 
that  there  are  small  areas  of  the  cortical  field  which  physiology  has 
not  yet  taken  up  ; the  most  important  of  these  is  the  inferior 
temporo-occipital  region. 

We  should  mention  still  further  what  relation  the  cerebellum 


Fig.  54. — Scheme  of  the  Psycho-physiological  Topography  of  the  External 
Aspect  of  the  Cerebral  Mantle.  The  Posterior  Dotted  Area — Occipito- 
parietal  IS  ALL  CONCERNED  IN  THE  VISUAL  FUNCTION. 

zl,  Zone  for  the  luminous  images  ; io,  zone  for  the  images  of  the  objects  ; ig,  zone 
for  the  graphic  images  (the  extent  of  each  is  approximately  indicated  by  the  size  of 
the  dots) ; u,  area  for  hearing  (the  large  dots  represent  the  auditory  images  of  words, 
wliich  do  not  possess  a special  area)  ; g,  zone  for  the  gustatory  images  ; zsm,  senso- 
motor  zone  or  tactile  zone  (according  to  some)  with  the  two  evolutive  areas  ; mp, 
motor  zone  for  articulate  speech  ; ms,  motor  zone  for  writing.  The  entire  surface 
situated  in  front  of  these  is  the  area  for  the  physiological  fusion  of  the  psycho-sen- 
sory products  elaborated  by  all  the  other  areas. 


has  with  the  psychic  functions,  but  the  observations  are  yet  too 
scant  to  admit  of  any  hypothesis  whatever.  No  one  should  fail  to 
record  observations  of  mental  weakness  of  all  those  in  whom  there 
is  demonstrated,  at  the  necropsy,  the  existence  of  profound  and 
extensive  lesions  or  defective  development  of  the  cerebellum.  In 
such  cases,  however,  there  have  been  found,  or  it  has  even  been 
possible  to  assume  a priori,  such  lesions  of  the  cerebral  hemi- 
spheres as  would  render  it  arbitrary  to  assign  to  the  cerebellar 
lesion  the  mental  decay,  or,  better,  the  weak  or  feeble  attempt  at 
mentalization. 

Nevertheless,  there  comes  to  be  accepted  and  accredited  in  the 


PHYSIOLOGY  OF  THE  CEREBELLUM 


175 

mind  of  one  who  reads  all  the  observations,  or  who  has  occasion  to 
follow  the  progress  of  such  affections,  the  supposition  that  the 
cerebellum  is  not  outside  the  sphere  of  the  intellectual  functions, 
to  which  it  appears  it  may  lend  vigour  and  power  of  resistance.  In 
a weighty  anatomico-physiological  synthesis  upon  the  neuraxis. 
Professor  Antonelli  {II  Nevrasse  nel  suo  insieme,  1899)  inclines  to 
admit,  not  without  good  reason,  that  the  cerebellum  may  be  the 
larger  centre  of  the  reflexes.  Considering  the  reflex  in  its  widest 
sense,  one  can  subscribe  to  the  hypothesis  of  the  distinguished  pro- 
fessor. But  the  cerebellum  seems  to  be  likewise  an  accumulator 
which  is  constantly  discharging  itself  through  the  numerous  afferent 
paths,  and  reinforcing  the  energy  of  the  cerebral  mantle.  The 
future  alone  will  reveal  the  part  which  the  cerebellum  plays  in  the 
work  of  the  cerebral  mantle.  A book  like  this  permits  of  only  a 
brief  allusion  to  the  great  problem. 


PART  II 

CHAPTER  I 

PHYSIO-PATHOLOGY  OF  PERCEPTION 

Various  authorities  have  compared  mental  with  somatic  life,  and 
have  sought  to  establish  parallels  in  the  development,  function,  and 
governing  laws  of  each.  Although  this  plan  has  not  met  with 
universal  approval,  it  cannot  be  denied  that  it  has  a good  founda- 
tion of  truth,  and  it  appeals  very  strongly  to  medical  men,  who  are 
in  the  best  position  to  utilize  the  rich  patrimony  of  biology,  and  to 
make  such  a method  productive  of  good  results.  Mind,  considered 
in  its  entirety,  is,  after  all,  only  the  other  aspect  of  life  ; it  is  con- 
stituted like  an  organism  that  has  its  evolutionary  story,  and  it  > 
is  governed  in  its  manifestations  by  fundamental  laws  common  to  = 
life  in  general.  Among  these  there  is  substantial  and  constant  . 
that  of  taking  from  the  external  world,  of  assimilating  the  energies  : 
of  Nature,  and  transforming  them  into  psychic  force.  The  body  , 
receives  and  transforms  matter,  the  mind  receives  and  transforms  | 
all  the  cosmic  energies  of  which  it  is  the  S3mthetic  equivalent.  As  ‘ 
life  may  commence  from  plastiduli  (Haeckel,  Maggi,  Erlsberg),  or 
from  gemmules  (Haacke),  or  from  physiological  molecules  (Spencer), 
one  can  agree  in  any  case  with  the  supposition  already  advanced  by  : 
many  {vide  Part  I.,  Introduction),  that  the  mind  may  commence  | 
in  these  same  primitive  elements,  and  that,  solely  by  a series  of  I 
transformations  and  accumulations,  it  then  manifests  itself  more  j 
clearly  in  the  unicellular  organisms  (the  amoebae  and  the  monadae),  ; 
and  still  more  so  in  those  organisms  in  which  the  first  nervous 
structures  become  apparent  through  successive  differentiation  of 
the  primitive  morphological  elements. 

As  it  is  without  the  scope  of  a treatise  such  as  this  to  take  up 
the  story  of  the  development  of  the  nervous  system  or  that  of  the 
mind,  and  much  less  that  of  comparative  psychology,  we  may 
limit  ourselves  here  to  the  statement  that  the  phenomenon  of 
reception  consists  in  nothing  else  than  the  action  of  the  cosmic 
energies  on  the  organism,  and  in  that  of  the  organism  modified  ufon 
the  cosmic  energies.  In  beings  with  an  evolved  nervous  system 
this  function  is  assumed  by  the  nervous  tissue. 

176 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


177 


This  action,  however,  is  very  soon  accompanied  by  the  notice 
of  it  by  the  organism  itself,  which,  then,  is  orientated  on  the  one 
hand  towards  the  agents  operating  upon  it,  and  on  the  other  to  the 
historical  formation  of  the  issue  of  the  action  in  question,  which, 
again,  generates  consciousness.  The  point  where  consciousness 
begins  is  the  starting-point  of  the  sensations,  which,  by  a process 
of  evolution  that  may  be  followed  philogenetically  and  ontogenetic- 
ally,  give  rise  to  the  perceptions  and  the  sentiments — that  is  to  say, 
to  successive  notions  and  to  successive  modifications  of  the  ego, 
which  are  the  two  fundamental  factors  in  psychic  life  and  in  all 
the  vast  and  complicated  mechanism  of  the  mind. 

Hence,  according  to  some,  sensation,  taken  in  a very  general 
sense,  would  consist  in  the  modification  induced  in  the  nerve  elements 
by  external  agents,  even  though  the  latter  should  not  be  noticed. 
To  prevent  confusion,  however,  and  to  avoid  all  possible  contro- 
\ ersies  and  doctrines  that  are  too  aprioristic,  and  surpass  the  limits 
which  I have  imposed  on  myself  in  this  work,  and  all  that  has  been 
mentioned  in  the  first  part  of  this  volume  with  regard  to  photo- 
tropic and  heliotropic  phenomena,  we  may,  without  any  risk,  set 
out  from  a clearer  point  by  defining  sensation  as  the  notice  of  the 
modification  induced  by  external  agents  (stimulus). 

This  definition  is  true  if  we  regard  sensation  from  a general 
point  of  view  in  the  zoological  scale,  or  if  we  look  at  certain  stages 
of  the  mental  development  of  man  or  the  higher  animals,  seeing 
that  the  simple  fact  of  noticing  is  almost  inadmissible  in  the  de- 
veloped man.  In  him  the  usual  sensory  process  is  complicated  and 
perfected  by  the  formation  of  concomitant  states,  by  means  of 
which  he  is  enabled  to  recognise  the  agent  and  to  refer  the  point 
where  the  stimulus  has  acted  to  the  periphery  of  the  body,  or  to 
space,  at  various  distances  and  in  diverse  spacial  relations  with  the 
external  world.  It  is  otherwise,  however,  in  the  case  of  the  first 
sensations  of  the  newly-born  infant,  while  it  has  not  yet  developed 
the  sense,  much  less  the  notions,  of  space,  and  sums  up  everything 
in  the  elementary  retinal  and  cutaneous  sensations  which  it  ex- 
periences and  with  which  is  confused  its  nascent  ego ; so  also  in  all 
those  beings  with  a nervous  system  in  process  of  evolution,  but 
still  very  simple  and  scattered,  in  which  case  we  can  admit  only 
simple  sensations,  with  likewise  simple  reflex  manifestations  repre- 
senting the  sole  cycle  of  their  psychic  life. 

Sensation  must  not  be  confused  with  perception.  It  merely 
furnishes  one  component  of  perception,  while  perception  furnishes 
all  the  fundamental  components  from  the  sum  of  which  arises  the 
notion  of  the  agent  and  its  precise  distinction  from  the  ego.  We 
might,  like  James,  suppose  the  distinction  that  we  would  in  this 
manner  draw  between  sensation  and  perception  to  be  suppressed, 
all  the  more  that  in  the  adult  and  evolved  man  it  is  almost  im- 
possible to  conceive  of  a simple  sensation  such  as  we  suppose  to 

I 12 


178 


PSYCHIATRY 


occur  in  star-fishes  and  molluscs,  or  even  in  newly-bom  mammals, 
and  we  might  limit  ourselves  to  the  very  concise  statement  that 
sensation  is  more  simple  than  perception.  To  me,  however,  it 
seems  more  opportune,  if  we  confine  ourselves  to  the  human  being 
beyond  the  stage  of  infancy,  to  speak  of  grades  of  perception,  and 
to  restrict  the  conception  of  sensation  to  that  process  in  which 
the  noticing  of  the  modified  ego  is  given  solely  by  the  external  com- 
ponent of  perception.  If  we  remove  the  cerebral  cortex  from  a 
dog  (Goltz),  or  the  hemispheres  from  a pigeon  (Flourent,  Lussana, 
Schiff,  and  many  others),  the  animal  still  has  visual  sensations, 
yet  does  not  perceive  ; it  does  not  show  that  it  recognises  objects, 
and  it  is  no  longer  able  to  estimate  distances.  This  shows  that 
even  the  subcortical  cerebral  organs  receive  and  transform  the 
waves  transmitted  from  the  receptive  organs  located  at  the  peri- 
phery of  the  body  in  immediate  relation  with  the  energies  of  the 
external  world.  Nevertheless,  though  this  process  of  reception  and 
transmission  to  a central  organ  constitutes  the  fundamental  fact  of 
sensation — that  is  to  say,  the  noticing  of  something  that  has  acted 
on  or  in  the  body — it  is  only  one  of  the  factors  of  perception.  To 
arrive  at  perception  we  must  have  the  concurrence  of  two  other 
factors  : the  motor  component  which  is  associated  and  fused  with 
the  sensory  component,  and  the  recognition  of  the  sensory  com- 
ponent, which  consists  in  the  association  of  the  present  sensory  . 
wave  with  past  sensory  residua,  similar  or  analogous  in  character.  ; 

These  two  components,  both  of  them  internal,  are  absolutely  ; 
necessary  for  the  formation  of  the  perceptions — that  is  to  say,  for  : 
perception — and  demand  a higher  development  of  the  nervous 
system,  either  in  the  form  of  associated  ganglionic  masses,  as  in  ? 
insects,  or  the  more  conspicuous  form  of  the  cerebral  mantle,  which 
is  superimposed  on  the  old  exclusive  organs  of  sensation  that  we  : 
find  in  the  invertebrates. 

The  conception  developed  in  the  first  part  of  this  work  regarding  ' 
the  importance  of  the  motor  element  in  the  formation  of  the  images  ^ 
— a conception  I have  held  since  1882 — finds  abundant  proof  in  the  I 
result  of  recent  experimental  researches.  Bourdon  has  demon-  j 
strated  that  monocular  perception  of  unknown  objects  is  derived  j 
especially  from  the  movements  of  the  head,  associated  with  the 
retinal  displacements  that  result  from  the  monocular  parallax. 

If  the  head  is  in  a state  of  immobility  the  perception  is  somewhat 
rudimentary  and  incomplete,  and  even  this  is  due  in  part  to  sensa- 
tions of  convergence  associated  with  the  changes  of  accommodation 
and  the  retinal  displacements  caused  by  fhe  movements  of  the  eyes. 

This  is  demonstrated  also  by  the  behaviour  of  infants  with  con- 
genital cataract.  Two  such  cases  have  been  reported  by  Vurpas 
and  Eggli  (Annie  psych.,  1895),  who  have  noted  that  sight  at 
first  gives  no  aid  in  the  judgment  of  distance  or  direction,  or  in  the. 
form,  extent,  and  curvature  of  objects.  - 


PHYSIO-PATHOLOGY  OF  PERCEPTION  179 

Sevfert  arii\es  at  the  same  conclusion  by  quite  another  method. 
He  affirms  that  the  principal  factor  permitting  the  exact  perception 
of  simple  forms  is  not  at  all  the  retinal  image,  but  the  muscular 
sensation  of  the  eyes.  As  the  result  of  these  researches  and  the 
analogous  ones  of  Bourdon,  Miinsterberg,  and  others,  it  is  beyond 
dispute  that  perception  is  not  a simple  factor,  but  results  from 
sensory  and  motor  components,  present  and  past,  in  more  or  less 
extensi\  e association.  Accordingly,  the  scheme  I have  put  forward, 
and  which  is  reproduced  below,  is  quite  justifiable.  The  other 
internal  factor  to  which  I alluded  a little  ago  is  the  recognition,  which 


T7  ^ 

Fig.  55.— Scheme  indicating  the  Course  of  the  Sensory  Waves  for  the 

FORMATION  OF  THE  CONCRETE  VISUAL  IMAGES,  THE  HiGHER  MenTAL  PRO- 
DUCTS, AND  THE  Reflexes  of  the  Various  Grades  [vide.  p.  106  et  seq.). 

consists  in  the  awakening  of  a state  of  consciousness  analogous  to 
one  set  up  on  some  former  occasion  under  the  action  of  an  identical 
or  similar  stimulus.  This  fact,  which,  at  bottom,  consists  in  the 
physiological  fusion  of  identical,  similar,  or  analogous  perceptions, 
at  different  times  and  under  different  circumstances,  impresses  the 
character  of  progressiveness  on  this  modality  of  the  psychic  process. 

Progressiveness  of  the  perceptive  process  is  met  with  as  a funda- 
mental law,  constant  throughout  both  the  philogenetic  and  the 
ontogenetic  story  of  perception.  This  furnishes  combinations  that 
are  more  complicated  the  richer  the  patrimony  (consisting  of 
combinable  components)  of  the  psychic  personality.  In  my  opinion 

12 — 2 


i8o 


PSYCHIATRY 


we  cannot  accept  the  hypothesis  of  Allin,  who  holds  that  percep- 
tion consists  in  the  reception  and  registration  of  the  features  of  the  ! 
present  fact,  without  intervention  of  the  mental  content  of  previous  I 
formation,  as  a result  of  good  observation.  On  the  contrary,  there 
seems  greater  probability  in  the  opposite  doctrine  upheld  by  Bain, 
Wundt,  Herbart,  Mill,  Holding,  James,  and  others,  that  the  per- 
ceptive process  refers  partly  to  the  present  fact  and  partly  to  the 
recognition  of  a large  or  small  number  of  features  (images)  which, 
through  former  acquisition,  have  become  a utilizable  capital  of  the 
personality,  which  every  da}^  grows  richer  in  new  perceptions,  that 
are  continually  entering  into  new  and  complex  combinations  with 
the  waves  penetrating  from  without  and  stimulating  the  perceptive 
process. 

The  image  that  the  infant  forms  of  an  orange  before  smell  and 
taste  are  developed  is  much  simpler  than  occurs  later  on,  when  it 
is  able  to  distinguish  the  smell  and  the  taste  of  the  orange,  these 
giving  rise  to  new  olfactory  and  gustatory  components,  which  enter 
into  combination  with  the  visual  and  tactile  components  in  order 
to  furnish  a more  complex  psychic  product.  Still  later  it  learns  the 
word  corresponding  to  the  object,  then  the  graphic  symbol  of  the 
word,  and  these  are  so  many  other  successive  components,  which, 
along  with  the  former,  enter  into  a combination  whose  increasing 
complexity  symbolizes  the  progressiveness  of  the  perceptive  process. . 

On  the  other  hand,  we  cannot  agree  with  those  who  profess , 
exclusively  the  doctrine  of  recognition  in  which  they  sum  up  per- ; 
ception.  Such  a doctrine  excludes  the  conception  of  progress,  which  : 
finds  its  only  national  explanation  in  the  perception  of  differences — 
that  is  to  say,  in  the  capacity  to  gather  new  features  and  new  ( 
relations  in  the  external  world,  as  well  as  to  furnish  new  and  useful ' 
combinations  with  the  perceptions  and  the  secondary  products  of 
these  that  have  accumulated  in  the  mind.  The  first  locomotive 
whose  shrill  whistling  and  laborious  puffing  were  heard  in  the  valleys  ’ 
of  the  Sannio,  I remember  as  a youth,  was  judged  by  the  astonished  ^ 
people  to  be  the  work  of  the  devil.  In  that  case  the  new  visual  and  | 
auditory  features  of  the  train  became  combined  with  the  psychic  ! 
content  of  the  mind  of  the  people  of  those  times,  a people  who  , 
attributed  every  new  and  surprising  affair  to  supernatural  forces. 

The  law  of  progressiveness  in  the  reception  and  combination  of 
the  ever-increasing  acquisitions  solves  also  the  question  of  the 
difference  between  perception  and  apperception. 

Here  we  experience  again  the  difficulty  we  found  in  defining  the 
difference  between  sensation  and  perception.  It  is  even  more 
difficult,  however,  to  distinguish  between  perception  and  apper- 
ception. In  fact,  while  in  the  story  of  the  development  of  the  mind 
we  meet  with  a moment  in  which  sensation, — taking  for  example  i 
the  visual  sensation  in  molluscs,  worms,  mammals,  and  infants, — I 
consists  in  a simple  noticing  of  light  until  several  days  after  birth,  ' 


PHYSIO-PATHOLOGY  OF  PERCEPTION  i8r 

there  being  no  trace  of  perception  of  the  luminous  objects,  but  merely 

evidence  of  luminous  sensation — which  is  a very  different  thing 

in  vain  do  we  seek  for  an  analogous  line  of  separation,  somewhat 
artificial  though  it  be,  between  perception  and  apperception.  The 
latter  consists  in  perception  courted  by  a much  larger  number  of 
associated  relations,  which  again  presupposes  the  conservation  of 
previous  psychic  formations,  with  which  the  new  percept  enters 
into  combination,  giving  rise  to  more  complex  judgments  and  a more 
perfect  notion  of  things  in  the  external  world  and  their  relations  with 
it.  Apperception  is  a more  acute  perception,  rendered  possible  by 
a more  concentrated  attention,  and  promising  results  of  much 
greater  advantage  for  the  evolution  of  the  mind  {vide  the  following 
chapter  on  attention).  It  is,  accordingly,  the  highest  expression  of 
the  perceptive  progressiveness. 

This  law  of  progressiveness  has  also  been  demonstrated  experi- 
mentally by  Luckey,  who,  examining  children  with  the* view  of 
determining  the  evolution  of  the  visual  field  for  colours,  and  hence 
the  retinal  sensibility,  found  that,  if  we  consider  the  retinal  sensi- 
bility  for  colours  in  the  adult  equal  to  lOO,  it  is  about  59  in  a boy  of 
■ thirteen  years,  and  about  37  in  one  of  seven  years.  It  is  probable 
that  the  retinal  sensibility  for  colours  may  increase  gradually  with 
exercise  in  each  individual,  and  especially  in  a particular  class  of 
workers.  In  fact,  according  to  the  researches  of  Kirschmann,  Pick, 

; Hess,  and  especially  of  Luckey,  the  retinal  surface  is  not  equally 
j sensible  to  colours  ; the  central  regions  perceive  colours  better  than 
the  peripheral.  Certain  it  is  that,  while  historically,  as  appears  from 
the  researches  into  the  ancient  lays  of  the  Veda  and  Zend-Avesta, 

; \\e  have  no  proof  that  all  the  colours  of  the  spectrum  were  then 
' known,  but  only  some  of  them — those  with  longer  vibrations  (red, 

I orange,  etc.)— the  number  of  the  nuances  and  the  distinction  of  the 
I colours  of  the  spectrum  is  at  the  present  day  extraordinarily  in- 
} creased.  Kfilpe  and  A.  Konig  have  determined  the  number  of 
I the  nuances  to  be  from  150  to  164,  and  the  number  of  the  distinc- 
tions from  660  to  696.  On  the  other  hand,  it  is  well  known  that 
I the  manufactures  of  Gobelins  of  Paris  include  18,000  nuances, 

I and  the  Italian  mosaics  still  more. 

; One  of  the  conditions  of  perception  is  that  the  stimulus  reach 
; a degree  of  intensity  sufficient  to  enable  it  to  overcome  all  the 
I resistance  it  meets  in  its  course,  and  to  cross  the  threshold  of  con- 
j sciousness.  There  is  an  infinity  of  weak  stimuli  that  we  fail  to 
j notice,  and  yet  we  must  admit  that  they  operate  on  the  peripheral 
ner\  ous  extremities  of  the  senses.  If,  while  we  are  listening  to  a 
uniformly  sonorous  body,  someone  remove  it  to  a distance  until 
we  no  longer  hear  any  sound,  no  matter  how  attentive  we  are,  and 
we  then  apply  a multiplicator  to  the  ear,  we  again  hear  the  noise 
or  the  sound  that  had  disappeared.  At  a certain  distance  on  a 
railway  that  runs  straight  for  several  kilometres  we  no  longer 


i82 


PSYCHIATRY 


notice  the  lights  of  a receding  train,  and  first  of  all  the  white  light 
disappears,  and  then  the  red  becomes  gradually  less  distinct,  till 
it  entirely  fades  from  view.  If,  now,  we  apply  a binocle  to  the  eyes 
the  lights  again  come  into  view.  This  shows  that  the  luminous 
waves  arrive  at  the  retina,  but  the  nerve-waves  into  which  they 
become  transformed  are  not  of  sufficient  intensity  to  overcome  the 
resistance  of  the  optic  paths  and  to  reach  the  sensory  zone  of  the 
cortex. 

The  importance  of  the  intensity  of  the  stimulus  is  demonstrated 
by  quite  a number  of  experimental  facts.  As  Bourdon  has  re- 
marked, the  distinctness  of  the  visual  perception  of  form  is  in  strict 
relation  with  the  visual  acuteness,  and  this  in  its  turn  is  closely 
allied  with  the  intensity  of  the  illumination. 

The  absolute  intensity  of  the  luminous  point  not  only  has  a 
notable  influence  on  the  perceptibility  of  objects,  but,  as  results 
from  the  experiments  of  Ashley,  increased  intensity  of  the  light 
gives  the  illusion  that  the  object  is  at  hand,  while,  on  the  contrary, 
diminished  intensity  of  the  light  gives  the  illusion  that  the  object 
is  at  a distance.  The  intensity  is  of  even  greater  value  when  con- 
cerned in  the  discrimination  between  two  sensations. 

If  the  distinctness  of  the  spectrum  become  gradually  diminished, 
we  arrive  Anally  at  a point  where  we  no  longer  discern  the  colours, 
but  see  only  a bright  held  (experiments  of  Kries  and  Hillebrand). 
The  purely  quantitative  anomalies  of  perception  may  all  be  corrected 
by  augmenting  the  intensity  of  the  stimulus,  and  this  independently 
of  the  co-efficient  of  imaginative  variation  introduced  by  Faucault 
(‘  Mesures  de  la  clerte  de  quelques  representations  sensoriellesf  Revue 
philosophique,  1896),  and  given  by  the  tendency  to  aggrandise 
(positive  co-efficient)  or  to  diminish  (negative  co-efficient). 

It  is,  however,  a matter  of  common  observation  that  when  the 
intensity  exceeds  a determined  degree,  variable  between  certain 
limits,  the  perception  loses  in  precision.  Everyone  knows  that  a 
loud  noise  gives  less  precision  as  regards  its  intrinsic  character, 
its  direction,  and  distance,  than  one  of  less  intensity  ; a painful 
stimulus  appears  to  occupy  a much  larger  cutaneous  surface  than  a 
tactile  stimulus  of  the  same  extent  ; a highly  luminous  body  cer- 
tainly dazzles,  but  it  is  not  perceived  in  its  particulars  (circles  of 
diffusion  in  the  retina  and  the  cortical  zone). 

Again,  the  duration  of  the  time  of  successive  perceptions  exerts 
a strong  influence  upon  the  perceptive  process.  When  two  stimuli 
operate  contemporaneously,  or  succeed  one  another  very  rapidly, 
the  perception  of  one  or  of  both  is  imperfect.  A kind  of  interfer- 
ence occurs  in  the  latter  case  and  a selection  in  the  former. 

This  fact,  which  everyone  can  prove  from  his  owm  experience, 
has  been  confirmed  experimentally  by  the  researches  of  Robinson. 
The  converse  of  this  same  law  explains  the  great  tactile  and  acoustic 
acuity  of  the  blind.  The  celebrated  pianist  Tabbozzi,  educated  at 


1 PHYSIO-PATHOLOGY  OF  PERCEPTION  183 

I 

I Naples  in  the  blind  institute  directed  by  Martuscelli,  possesses  a 
\ marvellous  perceptive  fineness — tactile,  muscular,  and  acoustic — 
' through  which  he  perceives  with  his  finger-tips  and  with  surpassing 
rapidity,  the  musical  notes  of  the  scores ; he  has  formed  a clear 
i notion  of  the  streets  traversed  by  him  in  Paris,  London,  Milan, 

; and  Palermo,  whither  he  went  to  give  concerts,  and  he  also  knows 
. the  topographic  disposition  of  the  furniture  in  any  drawing-room 
where  he  has  once  been  received : his  tactile  and  muscular  as 
well  as  his  acoustic  memories  permit  him,  when  new  pieces  are 
executed  by  others,  to  repeat  the  notes  on  the  piano,  and  to  rise  in 
a short  time  to  a perfection  of  execution  met  with  only  in  the 
great  masters  and  pianists. 

This  law,  however,  has  not  a few  exceptions.  In  some  cases, 
under  the  influence  of  a new  stimulus,  the  perceptive  power  for  a 
' given  sensation  is  increased.  Urbantschitsch,  and,  after  him. 
Tanner  and  Anderson,  have  furnished  experimental  proofs  of  this 
; fact.  If  we  determine  the  threshold  of  perception  for  a very  weak 
j colour  and  superadd  a stimulus,  it  may  be  of  a luminous  or  other 
nature — tactile,  auditory — the  supplementary  stimulus  renders  the 
colour  more  visible,  as  if  its  intensity  were  augmented.  One  sensa- 
tion may  have  a dynamic  genetic  influence  on  another  simultaneous 
sensation  of  a different  nature  (De  Sanctis). 

Within  certain  limits,  repetition  of  the  stimulus  renders  the  per- 
ception always  more  perfect,  as  in  the  case  of  increased  intensity. 
Exercise  augments  the  perceptive  power  to  a wonderful  extent. 
This  has  been  proved  by  Volkmann,  Vierordt,  and  more  recently 
by  Dresslar,  who  carried  out  numerous  experiments  on  the  cutaneous 
sensibility,  with  the  aid  of  Weber’s  compass  {American  Journal 
of  Psych.,  1894).  The  perceptive  acuteness  increases  rapidly 
from  18  millimetres  to  4 millimetres  of  distance  between  the  two 
points  of  the  compass.  This  is  due,  in  my  opinion,  to  attention, 
so  that  the  increase  ceases  after  a certain  time  as  the  process  becomes 
mechanical.  The  same  tactile  fineness  is  obtained  on  symmetrical 
parts  of  each  arm,  so  that  the  distance  is  found  to  be  diminished 
from  21  to  5 millimetres  on  both  sides  (increased  power  of  atten- 
tion and  discrimination). 

The  tactile  fineness  is  rapidly  lost  after  cessation  of  exercise. 
Age  exercises  not  a little  influence  upon  the  perceptive  power. 
Lnder  equal  conditions  of  exercise  and  sex,  the  tactile,  visual,  and 
auditory  sensibilities  vary  with  age.  Among  the  experiments  that 
afford  the  best  proof  of  this  statement  those  of  Zwaardemaker  upon 
hearing  appear  to  me  to  be  very  interesting  T Dcr  Umfang  des 
Gehors  in  den  vcrschiedencn  Lehensjahrenf  Zeitschr.  f.  Psych,  u. 
Physiol,  d.  Sinn.,  VIE).  He  has  demonstrated  that  the  upper 
limit  for  the  perception  of  sounds  is  highest  in  children,  and 
diminishes  slowly  up  to  thirty  years,  more  rapidly  from  thirty  to 
fifty-five  years,  and  then  slowly  again  up  to  eighty  years.  Speak- 


184 


PSYCHIATRY 


ing  generally,  the  extent  of  the  sonorous  scale  is  about  eleven  octaves 
in  infants,  diminishing  gradually  to  ten  octaves. 

The  sensation  of  time  comes  into  play  as  a constituent  element 
of  perception,  and  by  the  experience  of  that  sensation  we  form  our 
notion  of  time.  The  sense  of  time,  like  that  of  space,  presents  very 
great  difficulties  in  its  psychological  examination,  for  many  reasons 
—among  others  because  it  is  an  inseparable  component  of  percep- 
tion and  of  thought.  Whence  does  it  arise  ? How  is  our  notion 
of  time  formed  and  manifested  ? In  what  manner  are  the  immediate 
estimation  of  short  or  long  periods  and  the  measures  of  time  past 
and  time  to  come  rendered  possible  ? In  what  way  are  the  intui- 
tions of  the  duration  of  determined  psychic  facts  brought  about  in 
the  unconsciousness,  as  when  we  fix  the  hour  of  awakening  on 
going  to  bed  at  night,  and  when  a hypnotized  woman  who  has 
received  a suggestion  that  is  to  be  carried  out  in  due  time, 
fulfils  the  act  suggested  on  the  day  and  hour  fixed  in  the  hypnotic 
sleep  ? ^ These  are  problems  in  psychology  presenting  the  greatest 
difficulties. 

\\  e have  here  to  deal  with  the  question.  Does  there  exist  an 
immediate  sense  of  time,  or  does  it  become  formed  by  experience 
itself  of  the  sensations  and  perceptions,  inasmuch  as  we  compare 
durations  of  diverse  perceptions  or  diverse  representations,  series 
of  one  and  the  other,  and  the  duration  of  the  intervals  between 
succeeding  perceptions  and  between  series  of  perceptions  and  repre- 
sentations ? In  all  this  it  is  no  easy  matter  to  say  to  what  extent 
the  estimations  of  time  are  immediate  and  direct,  or  represent  a 
relation  between  the  times  of  the  perceptions  and  the  times  of  other 
psychic  processes,  between  the  times  of  the  intervals  and  those 
necessary  for  movements  and  series  of  movements,  in  relation  to  the 
spaces  traversed. 

It  is  well  to  take  into  account  also  another  factor  which  has  been 
well  studied  by  Meumann— viz.,  that  according  as  the  intervals  are 
brief  or  long  they  are  void  or  filled,  and,  in  the  latter  case,  according 
as  they  are  filled  by  continuous  impressions,  like  those  produced 
by  the  diapason,  or  by  discontinuous  impressions,  such  as  those 
produced  by  electric  sparks  or  by  blows  of  a hammer,  or  by  a com- 
plex act  such  as  reading,  the  appreciation  of  the  duration  varies. 
So  also  does  it  vary  according  as  the  interval  occurs  between  im- 
pressions made  on  different  senses. 

For  example,  the  interval  between  two  noises  produced  by  the 
liberation  of  sparks  seems  shorter  than  an  equal  interval  limited 
by  two  spaiks  seen,  and  appears  longer  than  an  equal  time  inter- 
posed between  two  tactile  sensations.  According  to  Meumann, 
there  is  every  reason  to  believe  that  the  judgment  of  time  depends 
also  on  particular  conditions  of  the  sensory  organ  ; this  is  proved 
by  the  other  experimental  fact  that  the  interval  between  two  sparks 


PHYSIO-PATHOLOGY  OF  PERCEPTION  185 

seen  with  indirect  vision  appears  longer  than  that  between  two 
sparks  seen  with  direct  vision. 

The  faculty  of  comparison  is  regarded  by  many  psychologists 
as  a means  of  understanding  the  intuition  of  time.  It  is  evident, 
however,  that  this  is  not  immediate,  but  is  an  effect  of  prolonged 
experience  and  exercise  of  the  intellect.  It  is  principally  a fact  of 
intelligence,  as  is  also  proved  by  the  researches  of  Schumann.  He, 
like  his  master,  G.  E.  Mueller,  holds  that  the  perception  of  time 
is  formed  in  the  same  way  and  by  the  same  process  as  the  repre- 
sentations of  quality  and  intensity  of  a sensation — that  is  to  say, 
by  the  process  of  comparisons — which  introduce  another  factor  of 
great  importance — the  application  of  attention.  In  fact,  the  judg- 
ment of  the  duration  of  the  sensations  and  of  the  intervals  varies 
with  the  intensity  of  the  attention. 

This  factor  suggests  to  Munsterberg  the  hypothesis  that  the 
appreciation  of  time  is  given  by  the  muscular  sensations  arising 
from  the  adaptation  of  the  organs  of  sense  for  the  reception  of  the 
signs  (in  the  experiments). 

The  judgment  of  two  intervals  of  time  would  result  from  the 
sensations  of  relaxation  and  tension,  and  from  the  duration  of 
these  in  the  muscles,  not  only  of  the  organs  of  sense,  which  are 
all  furnished  with  muscles,  but  also  of  the  neck,  shoulder,  and  respira- 
tory apparatus. 

According  to  the  observations  of  Bolton,  movem,ents  play  a 
conspicuous  part  in  the  formation  of  ideas  of  time  and  also  of 
rhythm.  Indeed,  most  individuals  who  hear  sounds  and  group 
them  together  perform  movements  with  the  head,  feet,  fingers,  or 
the  entire  body,  and  this  sometim^es  unconsciously.  If  these  move- 
ments are  suppressed,  so  also  is  the  rhythm  (Bolton).  Rhythm 
is  only  a m..odality  of  the  sense  of  time,  and  seems  to  respond  to  a 
general  law  of  life.  Meumann,  who  has  made  a very  accurate- 
study  of  it  (‘  Untersuchungen  zur  Psychologie  und  JEsthetic  des 
Rhythmus,^  Phyl.  Stud.  X.),  agrees  fundamentally  with  the  doctrine 
of  Wundt,  or  at  least  with  its  principal  features. 

-■\11  the  phenomena  of  rhythm,  according  to  Wundt,  belong  to 
a general  psychic  function,  by  which  many  impressions  are  grouped 
together  into  a single  representation,  which  embraces  them  all,  and 
arranges  them  in  point  of  time.  Here  we  are  dealing  especially 
with  auditory  im,ages,  whose  analysis  leads  to  the  representation 
of  an  interval  of  time.  The  variations  in  intensity  and  quality  of 
the  auditory  impressions,  and  the  variations  of  the  intervals  that 
separate  these  impressions,  and  which  give  rise  to  the  sensation  of 
time,  must  be  associated  with  another  factor  to  give  the  impression 
of  rhythm — the  factor  of  periodicity.  In  the  production  of  rhythm 
Wundt  considers  two  primary  forms,  the  binary  and  the  ternary. 
The  first  is  composed  of  a loud  noise  followed  by  a weaker,  the  second 
of  a loud  noise  preceded  and  followed  by  a weaker. 


i86 


PSYCHIATRY 


In  the  case  of  noises,  rhythm  seems  not  to  be  uniformly  preserved 
even  when  in  reality  it  is  ; so  that  some  noises  appear  more  intense 
than  others,  or  the  intensity  is  uniformly  maintained,  while  the 
noises  are  distributed  in  series  separated  from  one  another  by  variable 
intervals  of  time. 

Hence  the  notion  of  time  with  or  without  that  of  rhythm  arises 
through  an  intellectual  process.  We,  by  a rapid  synthesis,  may 
imagine  all  the  periods  of  time — seconds,  hours,  days,  weeks,  years, 
etc. ; this  takes  place  only  by  means  of  reassumptive  symbols, 
such  as  words,  which  express  a determined  time,  which,  if  long, 
cannot  be  represented,  but  only  analyzed.  Even  in  the  case 
of  this  representation  attention  finds  a place  in  the  primary 
perceptions. 

Miinsterberg  has  demonstrated  (Beitrlige  zur  exp.  Psych., 
Heft  IV.)  that,  of  two  equal  intervals  of  time,  the  one  containing 
the  elements  that  excite  the  attention  more  strongly  seems  the 
briefer.  Thus  it  is  that  words  seem  briefer  than  sounds  (of  equal 
times),  and  phrases  shorter  than  syllables  void  of  significance. 

Some  psychologists,  such  as  Wundt,  Dietze,  Mehner,  have  sought 
to  determine  experim,entally  the  number  of  impressions  that  can 
be  clearly  distinguished  in  a given  unit  of  time.  Wundt  has  fixed 
the  num.ber  at  12,  provided  they  succeed  one  another  with  a certain 
rhythm  and  at  intervals  of  not  less  than  0-3  and  not  more  than  0*5 
of  a second.  The  time  varies  but  slightly,  as  is  shown  by  the 
experiments  of  Dietze,  even  if  the  total  number  of  impressions 
perceived  be  increased  up  to  40,  provided  they  are  distinguishable 
into  subgroups — e.g.  (if  experimenting  with  gunshots),  five  groups 
of  eight  shots  each,  or  eight  groups  of  five  each. 

Further,  this  time  may  vary  between  certain  limits,  not  only 
among  the  subjects  of  experiment,  but  also  among  the  different 
observers,  and  especially  is  it  abbreviated  by  practice,  which  renders 
the  sense  of  time  more  acute. 

We  have  already  pointed  out  how,  by  means  of  synthesis  and 
analysis,  we  are  able  to  represent  to  ourselves  past  times  of  great 
length  e.g.,  many  notable  features  in  our  lives.  These  repre- 
sentations are  influenced  in  an  illusory  manner  by  the  age  at  which 
we  have  arrived,  and  by  the  number  and  form  of  the  impressions 
that  have  occupied  the  time  gone  by.  ‘ In  general,’  says  James, 

‘ a time  filled  with  varied  and  interesting  experiences  seems  short 
in  passing,  but  long  as  we  look  back.  On  the  other  hand,  a tract 
of  time  empty  of  experiences  seems  long  in  passing,  but  in  retro- 
spect short.’  In  my  opinion,  the  explanation  of  this  phenomenon 
lies  in  the  fact  that  states  of  consciousness — involving  more  or  less 
disintegration  of  the  nervous  system — are  variously  associated  with 
the  sense  of  time,  since  the  stronger  they  are  the  deeper  is  the  im- 
pression they  make,  and  the  more  readily  are  they  reproduced.  The 
more  images  reawakened  on  reviewing  the  past  time,  the  longer  does 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


187 


that  time  appear.  If  to  old  people,  and  especially  to  those  who  have 
experienced  the  discipline  of  school  and  exaggerated  parental 
authority,  the  first  years  of  youth  seem  to  have  been  very  long  and 
the  latter  years  very  short,  then  it  would  appear  that  this  phe- 
nomenon should  be  attributed  to  the  fact  that  in  the  young  man 
the  sensations  are  stronger  and  the  memory  more  resisting  ; while 
in  the  old  man,  although  the  former  is  weaker  and  the  latter  less 
resisting,  all  past  sensations,  as  James  says,  form  an  automatic 
routine  not  rejected  or  completely  substituted  by  the  new. 

All  perceptions,  however,  contain  yet  another  element  which 
enters  indissolubly  into  the  perceptive  process — the  sense  of  space. 
The  sense  of  space  is  developed  by  a series  of  experiments,  in  which 
several  sensory  organs  participate.  Notwithstanding  all  arguments 
on  the  subject,  the  infant  in  the  first  weeks  of  his  life  has  not  yet 
formed  spacial,  visual,  tactile,  or  muscular  ideas,  and  when  he  ex- 
tends his  hand  to  grasp  some  far-off,  shining  object  he  shows  that 
he  does  not  yet  know  how  to  measure  distance.  The  intuitive 
estimation  of  distances,  of  the  spacial  relations  of  things,  their 
extent  and  their  volume,  can  only  have  origin  in  the  synthesis  of 
infinite  elementary  spacial  images,  to  whose  formation  different 
sensory  organs  contribute,  with  the  co-operation  of  and  by  means  of 
associative  paths.  Every  sensation,  or  rather  perception,  is  associ- 
ated with  spacial  sensations,  which  are  coalescent  with  the  sensory 
phenomenon,  and  cannot  be  separated  from  it  except  by  means  of 
psychological  analysis.  When  we  touch  an  object,  or  take  it  in 
our  hands,  we  perceive  not  only  the  tactile  qualities,  but  also  the 
extent,  form,  and  volume.  If,  by  education,  we  have  formed  the 
image  of  a minimum  unit  of  spacial  measure,  and  in  a given  unit 
of  time  we  pass  through  our  fingers  a ribbon  100  metres  long  with 
our  eyes  closed,  we  will  know  how  to  calculate  approximately  the 
length  of  the  ribbon  by  mentally  summing  together  the  units  of 
measure  perceived  by  touch  only.  If,  on  the  other  hand,  we  move 
the  fingers  and  all  the  upper  limb  in  every  direction  over  a fixed 
surface,  we  have  a much  better  perception  of  the  spaces  covered, 
and  judge  them  more  exactly,  because,  in  addition  to  the  tactile 
impressions,  we  have  the  concurrence  of  the  muscular,  aponeurotic, 
articular,  etc. 

In  another  part  of  this  work  I have  explained  how  visual  images 
are  formed,  their  motor  component  giving  rise  to  the  image  of  the 
form  of  the  objects,  their  volume,  and  their  spacial  relations. 

The  displacement,  on  the  macula  lutea,  of  the  image  which  is 
reflected  on  the  visual  field  in  every  direction  is  produced  by  the 
muscular  movements,  which  give  rise  to  the  tactile  sensations  that 
are  always  associated  with  the  movements. 

I would  add  here  that  the  alterations  in  the  curvature  of  the 
crystalline  lens  in  accommodation,  and  especially  when  there  is 


i88 


PSYCHIATRY 


effort  at  accommodation,  appear  to  be  associated  with  particular 
sensations.  The  changes  in  accommodation  and  the  accompanying 
pupillary  changes  are  not  without  effect  on  the  size,  intensity,  and 
distinctness  of  the  images. 

Alterations  of  accommodation  are  associated  with  alterations 
of  convergence,  and,  according  to  the  experiments  of  Dixon  (‘  On 
the  Relation  of  Accommodation  and  Convergence  to  our  Sense 
of  Depth,’  Mind,  1895),  of  Kirschmann  {Philo sophische  Studien 
di  Wundt,  1894),  and  of  Hillebrand  {Des  Verdhdltniss  von 
Accomodation  und  Konvergenz  zur  Tiefenlocalisation,  1894),  these 
alterations  take  no  small  part  in  the  perception  of  distance  and 
especially  of  depth.  It  is  true  that  sensations  of  convergence 
cannot  be  distinguished  from  retinal  sensations,  but  it  seems  certain 
that  they  contribute  to  the  formation  of  the  spacial  images,  and 
especially  those  of  depth.  Again,  according  to  Bourdon  (Annee 
psychologique,  1897),  the  absolute  knowledge  of  the  depth  of  the 
fixed  point  is  due  to  convergence. 

The  localization  of  sounds,  which  physiologically  resolves  itself 
into  the  mechanism  of  peripheral  projection,  has  been  variously 
interpreted  by  different  experimenters  and  psychologists.  Accord- 
ing to  Stumpf,  a sound  possesses  a characteristic  quality  in  every 
ear,  a local  sign  that  supplies  material  for  the  mental  constructions 
of  the  judgments  of  localization  by  way  of  associations.  Such 
judgments  depend  also  on  the  differences  in  intensity  of  the  sounds 
for  each  ear  (Kries  and  Bloch)  ; or  on  the  variations  of  the  action  of 
the  sounds  on  the  semicircular  canals,  according  to  the  position  and 
space  of  the  sonorous  bodies.  It  is  not  improbable  that  the  move- 
ments of  the  body,  when  it  is  directed  towards  the  source  of  the 
sound  (Miinsterberg  and  Pierce),  concur  in  their  formation. 

Here,  then,  we  have  to  do  with  a very  complex  function  in  which 
there  concur  the  impressions  on  the  semicircular  canals  {vide  the 
wealth  of  literature  dealing  with  these  organs,  particularly  the  works 
of  Stefani  and  Lugaro),  the  tacto-muscular  impressions,  and  the 
psychic  associations,  with  participation  of  the  whole  psychic  per- 
sonality. Indeed,  I believe  that  we  may  support  the  opinion  of 
Bechterew,  which  agrees  for  the  most  part  with  that  expressed  by 
Milhaud,  namely,  that  the  projection  into  space  is  not  possible 
except  by  the  intervention  of  the  consciousness  of  the  proper 
position  in  space  and  the  particular  spacial  relations,  and  this  in 
turn  is  founded  on  the  synthesis  of  the  impressions  upon  the  organs 
of  equilibrium  (Bechterew)  and  the  imaginative  transportation  of 
the  individual  personality  into  the  most  diverse  positions  in 
space,  thanks  to  the  auditory  and  visual  spacial  reminiscences 
(Milhaud). 

M e perceive  also  by  a series  of  experiments  whether  a sound  is 
produced  very  near  or  very  far  from  us.  Who  can  tell,  for  example, 
the  inlinite  number  of  experiments  made  by  an  infant  on  hearing 


PHY SIO-PATHOLOGY  OF  PERCEPTION  189 

the  voice  of  its  mother  at  the  most  diverse  distances,  and  in  the 
most  varied  directions  ? 

The  nipple  of  the  breast  already  constitutes  a unit  of  measure 
for  the  infant,  and  it  is  through  it  that  the  spacial  images  (form, 
volume)  of  everything  introduced  into  the  mouth  become  formed. 

Smell  alone  contributes  little  or  nothing  to  the  formation  of 
spacial  images,  and  those  which  sometimes  seem  to  be  awakened 
under  an  olfactory  impression — such  as  one  of  direction — or  even 
those  of  the  substances  or  objects  from  which  the  odours  emanate, 
are  only  secondary  images  already  associated  with  determined 
odours. 

Each  of  the  other  senses,  then,  gives  a more  or  less  apparent 
contribution  towards  the  formation  of  ideas  of  space,  and  most  of 
all  sight  and  the  muscular  sense  of  the  limbs,  neck,  and  trunk. 

If,  however,  we  exclude  the  sense  of  direction  and  orientation, 
which  is  a more  complex  formation,  the  sense  of  space  entering  into 
it  as  one  of  the  components,  and  which  to  a very  large  extent  is 
given  by  the  semicircular  canals  (and  hence  by  the  cerebellum),  all 
the  other  derivatives  of  such  sensations  and  spacial  images  become 
included  in  the  tacto-muscular  sphere,  because  they  are  all  reduced 
to  tacto-muscular  sensations  and  to  deep  sensations  coming  from 
the  articulations  and  the  annexes. 

As  the  elementary  spacial  images  gradually  become  formed, 
they  are  not  only  associated,  by  an  intrinsic  law  of  formation,  with 
the  respective  sensory  image,  without  which  the  muscular  sensation 
does  not  give  a utilizable  product  (as,  for  example,  an  individual 
suffering  from  congenital  blindness  can  readily  move  the  ocular 
bulbs  in  the  direction  of  the  various  meridians,  although  in  the 
absence  of  the  retinal  images  those  movements  do  not  take  any 
part  at  all  in  the  formation  of  spacial  images),  but  are  also  associated 
with  one  another  in  innumerable  series  which  the  mind  can  analyze, 
reducing  all  the  distances  and  all  the  volumes  to  the  least  percep- 
tible, or  synthetize,  multiplying  them  to  the  infinite,  as  when  we 
imagine  the  extent  of  the  oceans  or  the  volume  of  the  earth  or  that 
of  the  sun. 

What  occurs  in  all  other  ideas  takes  place  also  in  the  formation 
of  ideas  of  space.  Just  as  the  image  that  I have  formed  of  the  pen 
is  not  only  tacto-muscular,  but  also  visual,  and,  if  we  like,  even 
auditory — insomuch  as  when  writing  we  produce  from  time  to  time 
the  particular  noise  of  friction  or  scraping  of  the  pen-point  on  the 
paper — so  the  spacial  images  that  are  formed  and  are  forming  by 
means  of  the  different  organs  and  sensory  nervous  apparatus  blend 
together  by  association,  and  give  rise  to  the  notion  of  true  space, 
and  support  one  another  every  time  a spacial  judgment  is  required 
by  an  impression  occurring  through  a single  sense. 

In  this  it  is  quite  apparent  that  many  other  mental  factors 
besides  association  come  into  play,  and  especially  the  imagination 


190 


PSYCHIATRY 


(which,  after  all,  can  only  be  realized  through  association),  atten- 
tion, and  that  selective  capacity  of  the  mind  by  means  of  which 
images  are  categorized  according  to  features  of  resemblance,  analogy, 
difference  or  contrast,  thus  producing  from  chaos  a condition  of 
order  in  the  consciousness  with  regard  to  the  innumerable  sensations 
that  have  gone  on  accumulating  from  the  earliest  days  of  life.  The 
long  experience  of  the  actual  sensations,  associated  with  old  sensa- 
tions and  with  the  products  of  analysis  and  synthesis,  gives  us  the 
intuition  of  a larger  or  smaller  quantity  of  spacial  points  in  a single 
real  space  (synthetic  judgment),  besides  the  intuition  of  the  spacial 
relations,  which,  after  all,  are  only  differential  judgments  of  extent, 
form,  and  volume  of  objects  placed  in  proximity  or  at  a distance 
from  one  another  in  simultaneous  or  successive  order.  The  same 
holds  good  for  the  mental  formations  of  the  relations.  From  this 
there  arises  also  the  localization  of  objects  in  definite  space  along 
with  their  relations  according  to  simultaneous  or  successive  order. 

In  the  mental  construction  of  the  infinite  relative  spaces,  sight 
and  the  tacto-muscular  sense  play  a very  important  part,  as  we  have 
already  seen,  the  latter  more  especially,  inasmuch  as  the  mental 
spacial  formations  of  sight  are  possible  through  the  tacto-muscular 
products  of  the  ocular  movements,  which  give  rise  to  displacements 
of  the  retinal  image.  From  this  point  of  view,  Berkeley  is  not 
altogether  wrong  in  attributing  the  formation  of  the  spacial  notions 
to  the  muscular  sense  alone,  although  severely  criticised  by  James, 
and  not  without  good  reason.  James,  in  fact,  utilizing  the  results 
of  the  researches  of  Goldscheider — according  to  which  authority 
the  immediate  perception  of  the  movements  of  the  limbs  is  given, 
not  by  the  movements  per  se,  but  by  the  impressions  that  arise 
from  the  displacement  of  the  articular  surfaces — concludes,  on  the 
strength  of  a series  of  arguments,  not  always  happy,  that  the  dis- 
placements of  the  articular  surfaces  play  the  principal  part  in  the 
formation  of  the  sense  of  space.  ‘The  joint -feeling,’  says  James, 

‘ can  excellently  serve  as  a map  on  a reduced  scale,  of  a reality 
which  the  imagination  can  identify  at  its  pleasure  with  this 
or  that  sensible  extension  simultaneously  known  in  some  other 
way.’ 

In  my  opinion  this  conclusion  has  a great  deal  of  truth  in  it,  but 
compared  with  the  really  important  researches  of  Miinsterberg  and 
of  Bourdon  it  is  somewhat  exaggerated.  The  muscular  sense  is 
in  itself  very  complex ; on  the  one  hand  it  furnishes  the  elements 
for  the  judgment  of  weights  and  for  the  sense  of  fatigue  ; on  the 
other  hand,  it  concurs  either  with  these  elements,  as  Miinsterberg 
maintained,  or  with  the  tactile  elements  in  the  formation  of  the 
spacial  images. 

The  experiments  practised  on  paralyzed  limbs,  with  muscles 
atrophied  and  degenerate,  for  the  purpose  of  demonstrating,  by 
passive  movements,  the  formation  of  the  images  of  displacement 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


191 


of  the  limbs,  and  hence  the  images  of  the  spaces  traversed  by  such 
limbs  between  two  given  positions  by  means  of  the  successive 
articular  contacts,  do  not  give  evidence  in  favour  of  the  absolute 
value  of  the  sensibility  of  the  articular  heads  in  the  formation  of 
the  notions  of  space,  because  the  displacement  is  noticed  even  in 
limbs  that  are  completely  atrophied,  such  as  those  we  meet  with  in 
cases  of  acute  poliomyelitis  of  long  standing,  where  the  articular 
ligaments  are  relaxed  and  the  articular  surfaces  (when  the  patient 
is  in  a horizontal  position)  do  not  meet  perfectly.  These  facts  lead 
us  to  the  conclusion  that  not  only  the  articular  surfaces,  but  also 
the  muscles — in  so  far  as  they  possess  sensibility — the  tendinous 
and  aponeurotic  annexes,  and  the  integuments  furnish  impressions 
which  enter  as  components  into  the  notions  of  space  {vide  Henry, 
Parrisch,  and  others). 

Perception,  moreover,  is  a psychic  fact  which,  like  all  other 
phenomena  of  Nature,  is  not  exempt  from  the  law  of  time.  This 
might  be  formulated  substantially  as  follows  : Perception  always 
requires  a certain  time  for  its  fulhlment.  This  varies  in  length, 
increasing  in  proportion  to  the  complexity  of  the  object  of  percep- 
tion, and  diminishing  with  the  exercise  of  the  senses  and  the  in- 
tellect. 

This  field  of  study  was  made  the  subject  of  experiments  by 
Wundt,  Cattel,  Fischer,  Fechner,  and  Delboeuf,  and  has  been  culti- 
vated with  enthusiasm  in  Italy  by  Buccola,  Morselli,  and  others. 
The  results  that  have  accrued,  considered  either  in  them.selves  or 
in  the  application  that  has  been  made  of  the  method  of  study  to 
other  psychic  phenomena,  as,  for  example,  to  memory,  have  been 
of  very  great  service  to  psychology,  and  have  given  useful  and  prac- 
tical indications  as  well  as  abundant  promises  to  pedagogy. 

If  in  combination  with  a chronoscope,  such  as  that  of  Hipp  or 
any  other  with  which  it  is  possible  to  measure  hundredths  and 
thousandths  of  a second,  we  use  other  apparatus  by  means  of  which 
we  can  produce  a sound,  or  let  fly  an  electric  spark  (as  with  the 
Gesler  tubes),  or  provoke  a tactile  sensation  in  such  a way  that  the 
moment  of  stimulation  and  that  of  perception  are  signalled,  we 
always  find  that  between  the  two  moments  there  has  elapsed  a 
time  corresponding  to  the  nervous  psychic  process.  This  is 
divisible  into  the  times  for  the  passage  of  the  nerve-wave  pro- 
voked by  the  stimulus  to  the  perceptive  centre,  for  the  simple 
perception  either  with  discrimination  or  with  discrimination  and 
selection,  and  for  the  reaction  by  means  of  which  the  subject  of 
experiment  gives  with  a determined  m,ovement  the  signal  of 
perception  having  taken  place. 

The  time  of  perception  can  accordingly  be  divided  into  that  of 
the  simple  perception,  the  discrimination,  and  the  reaction,  and,  as 
was  proved  by  Buccola  better  than  any  other,  varies  very  much 


192 


PSYCHIA  TRY 


with  the  nature  of  the  senses  experimented  upon,  with  the  intensity 
of  the  stimulus— according  to  the  law  of  Weber  developed  by 
Fechner— with  the  number  of  the  stimuli,  with  the  mental  state, 
and  with  the  education  of  the  individual,  normal  or  abnormal. 

I quote  here  some  figures  from  Buccola’s  book,  which  to-day 
remains  still  fresh  and  instructive.  The  physiological  time  for  the 
optic  excitations  varies  from  0-222  of  a second  (Wundt)  to  0-150 
(Exner)  ; that  for  the  acoustic  from  0-182  (Wittich)  to  0-120  (Kreis)  ; 
that  for  the  tactile  from  0-201  (Wundt)  to  0-117  (Kreis)  ; that  for 
the  gustatory,  on  the  point  of  the  tongue,  varies  from  0-1598  to 
0-597  (^vith  sodium  chloride),  and  from  0-219  to  0-993  (with  quinine), 
according  to  the  researches  of  Buccola.  The  results  obtained  by 
Buccola  in  measuring  the  physiological  time  for  the  olfactory  per- 
ceptions are  very  different. 

The  perception  time  increases  very  much  when  the  same  part 
is  subjected  to  stimuli  of  diverse  nature.  Thus  Buccola  obtains 
0-140  of  a second  as  the  time  for  simple  contact  at  the  base  of  the 
tongue,  while  for  the  gustatory  perception  of  sodium  chloride  he 
obtains  the  much  longer  time  of  0-543. 

The  intensity  of  the  stimulus  exercises  no  small  influence  on 
the  physiological  time.  For  example,  according  to  the  experi- 
m.ents  of  Kries  and  Auerbach,  the  sound  produced  by  the  discharge 
of  the  electric  spark  requires  a perception  time  of  0-139  0-142 

if  the  tension  is  high,  and  a longer  tim.e,  from  0-157  to  0-158,  if  low. 

In  judging  the  length  of  these  times  we  must  distinguish  the 
time  necessary  for  the  conduction  of  the  centripetal  nerve-wave 
from  the  periphery  to  the  centre,  and  the  centrifugal  wave  from  the 
centre  to  the  spinal  medulla,  and  from  the  spinal  medulla  to  the 
muscles  of  the  forearm  for  the  movements  of  the  said  limb,  and  of 
the  finger  that  gives  the  signal,  from  that  which  is  required  by  the 
psychic  centres  for  the  process  of  perception.  Let  us  suppose,  after 
Richet,  a time  of  physiological  perception  equal  to  0-150  of  a second. 
From  this  we  must  subtract  : (i)  for  time  lost  in  the  muscles  of 
the  arm  and  hand,  0-010  ; (2)  for  transmission  of  the  nerve-current 
from  the  periphery  to  the  centre,  and  vice  versa  (30  metres  to  the 
second),  and  for  the  length  of  a metre,  0-033  ; duration  of  the 
passage  in  the  spinal  medulla  (5  metres  to  the  second),  0-025.  Total 
duration,  then,  of  the  time  for  the  passage  in  the  nervous  and 
muscular  apparatus,  0-068;  subtract  this  from  0-150,  and  the  re- 
mainder represents  the  time  required  for  the  process  of  perception. 

This  time  is  greatly  augmented  in  compound  perception  (Mor- 
selli),  demanding  discrimination  and  selection.  As  the  time  of 
transmission,  that  is  to  say,  0-068  of  a second,  varies  for  the  different 
senses  and  the  different  paths,  the  time  of  perception  varies  according 
to  the  simplicity  or  complexity  of  the  object  of  perception,  and 
as  it  calls  into  play  discrimination  or  discrimination  with  selection. 

To  discern  between  two  objects,  one  white  and  one  black, 


PHYSlO-PAfHOLOGY  OF  PERCEPTION 


193 


the  time  of  perception  with  reaction  was  found  by  Wundt  in  three 
individuals  to  be — 

0-050  of  a second. 

0-047 

0-077  „ 

On  adding  to  these  two  others,  a red  and  a green,  the  time  of  per- 
ception with  reaction  increased  to — 

0-157  of  ^ second. 

0-073  „ 

0-132  „ 

In  the  case  of  the  tactile  sensations  in  two  parts  of  the  body  of 
different  sensitive  power  Buccola  obtained  the  following  results  : 

I.  Simple  reaction  to  the  stimulus  of  contact  at  the  tip  of  the 
finger,  0-146  ; in  the  lower  third  of  the  forearm,  0-149  ; if  the  indi- 
vidual had  to  discriminate  between  the  two  zones  of  the  cutaneous 
surface  stimulated,  the  mean  time  of  reaction  rose  to  0-177  for 
the  point  of  the  finger,  and  to  0-194  for  the  lower  third  of  the 
forearm. 

If  in  addition  to  the  discrimination  the  subject  was  requested 
to  fulfil  a determined  volitional  movement  according  to  the  site 
of  the  stimulus,  the  time  of  reaction  was  further  increased  by  the 
selection  to — 

0-201  for  the  tip  of  the  finger. 

0-223  for  fho  lower  third  of  the  forearm. 

This  general  law  can  be  applied  to  all  degrees  of  discrimination  and 
selection,  and  to  all  the  senses  ; it  is  only  the  figures  that  vary, 
and  in  applying  the  law  to  the  more  obvious  facts  of  life  we  find 
it  to  correspond  to  a fact  which  all  may  observe— namely,  that 
under  equal  conditions  the  more  complicated  the  position  and 
adaptations  of  an  individual  in  his  social  relations,  the  longer  is  the 
time  required  for  discrimination  and  selection.  In  this  case  many 
other  factors  intervene — among  them  the  manner  of  feeling  (the 
interest),  which  contributes  to  the  increased  pressure  of  the  dis- 
charge from  the  motor  centres,  and  the  rapidity  of  association, 
which  furnishes  a greater  number  of  elements  of  recognition,  and 
contributes  to  the  increase  of  the  volitional  tensions. 

This  other  datum  is  closely  allied  to  the  law  of  Weber-Fechner — 
reduced  to  more  probable  terms  by  Ebbinghaus  and  by  James — 
concerning  the  influence  of  the  intensity  of  the  stimulus  upon  the 
time  of  reaction.  For  this  question,  however,  and  for  other  par- 
ticulars regarding  the  laws  of  the  time  of  reaction,  I refer  the  reader 
to  works  on  psychology,  being  obliged  to  consider  what  we  have 
said  up  to  this  point  as  sufficient  for  the  comprehension  of  the 
phenomenon  of  perception. 


13 


194 


PSYCHIATRY 


Anomalies  of  Perception. — The  process  of  sensation,  or  rather  of 
perception,  may  become  altered  in  various  manners.  Distinction 
IS  drawn  between  quantitative  and  qualitative  disturbances,  as 
well  as  those  that  have  regard  to  the  time  occupied  in  perception 
and  m reaction  ; the  latter,  however,  may  be  referred  to  the  former. 
\^e  can  have  a simple  defect  of  perception  when  the  subject  is  able 
to  take  in  only  some  of  the  attributes  of  an  object,  thus  causing  the 
notion  gained  of  the  object  itself  to  be  incomplete.  Such  a defect 
of  perception  may  depend  upon  the  incapacity  to  notice  and  to 
register  all  the  stimuli,  which,  according  to  general  experience, 
may  be  received  in  a given  unit  of  time.  This  condition  is  entirely 
dependent  upon  the  degree  of  development  of  the  brain,  and  is 
attributable  to  the  fact  that  the  nerve-elements  are  insufficient  in 
number  or  incompletely  developed,  and  hence  are  incapable  of 
elaborating  in  the  first  place,  and  of  furnishing  in  the  next,  a product 
that  is  of  sufficient  utility  for  the  work  required.  Further,  this 
may  depend  upon  chemical  conditions  or  other  anomalies  of  the 
peripheral  organ— ^.g.,  a deficiency  in  the  retinal  pigment  necessary 
for  the  differentiation  of  colours  (Konig).  It  is  very  difficult  to 
say  whether  Daltonism  is  caused  by  such  a condition  or  due 
to  a central  defect.  Certain  it  is  that  the  state  of  the  peripheral 
sensory  apparatus  has  a great  influence  upon  the  readiness 
and  precision  of  perception.  As  regards  Daltonism,  some  have 
divided  those  affected  into  groups  — those  who  are  blind 
for  blue  and  yellow,  and  those  who  are  blind  for  red  and  green. 
Such  a division,  however,  is  subject  to  many  variations.  Kirsch- 
mann  has  observed  the  case  of  a man  who  was  blind  for  green, 
yellow,  and  violet,  and  another  for  orange  and  indigo.  Very  many 
such  varieties  are  found,  as  we  are  assured  by  the  oculists  who 
examine  the  candidates  for  railway  employment.  Again,  it  has 
been  observed  that  when  the  perceptibility  for  a certain  colour  is 
defective,  that  for  the  complementary  colour  may  remain  unaltered. 
Idiots  and  imbeciles  furnish  examples  of  marked  defects  in  per- 
ceptibility for  colours,  especially  those  of  short  vibration,  such  as 
green  and  violet. 

In  a large  class  of  cases  the  perceptive  defect  arises  from  the  fact 
that  the  elements  productive  of  the  necessar^^  functional  energy 
are  insufficient  in  number,  and  have  not  reached  the  degree  of 
formative  evolution  met  with  in  individuals  who  are  fully  developed  ; 
nor  have  the  associative  paths,  by  means  of  which  the  physiological 
iiision  of  the  senso-motor  components  of  perception  is  rendered 
possible.  The  same  may  be  said  of  all  those  degenerative  processes 
that  go  from  cytolysis  to  cytoclasis,  and  of  all  those  alterations 
gi\ing  lise  to  a break  in  the  paths  of  communication.  Sometimes 
insufficiency  or  delay  in  perception  may  arise  from  concentration 
of  the  attention  (a  condition  we  hnd  very  frequently  in  the  insane) — 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


195 


that  is  to  say,  from  a strong  cerebral  potential — upon  an  extraneous 
order  of  psychic  components  (objects,  hallucination,  ideas,  emotional 
states). 

When  only  some  features  are  appraised,  they  are  usually  those 
of  stronger  vibration,  while  the  others,  because  of  their  more  delicate 
and  weaker  vibration,  are  neglected. 

In  the  case  of  a picture,  the  imbecile,  the  more  he  approaches  to 
idiocy,  will  notice  only  some  rather  striking  colour,  or  some  such 
coarse  and  outstanding  feature  ; he  will  be  incapable  of  noticing 
as  many  other  particulars  about  it  as  come  under  the  observation 
of  an  individual  normally  developed  and  trained,  and  this  results 
either  because  the  nerve  - elements  are  deficient  in  number,  and 
hence  insufficient  to  furnish  the  coefficient  of  work  necessary  to 
sum  up  and  transform  the  specific  vibrations  of  the  external  world, 
or  because  they  are  unadapted  to  transmit  them  as  psychic  waves, 
inasmuch  as  the  transmission  through  the  associative  paths  pre- 
supposes an  exponent  of  energy  (to  overcome  the  resistance  of  con- 
ductors) which  the  nerve-elements  of  the  phrenasthenic  are  incapable 
of  producing.  The  nuances  of  the  colours  are  not  within  the 
range  of  the  idiot’s  brain. 

For  example,  on  presenting  a watch  to  an  idiot  he  will  notice 
simply  a mass  of  a certain  shape  and  the  brilliancy  of  the  metal, 
and  may  by  chance  be  able  to  associate  here  also  the  image  of 
another  body  which  he  has  seen  similar  to  the  one  in  question, 
or  even  the  memory  of  the  tick-tack,  which  is  so  pleasing  to  the 
idiot  that  he  quickly  puts  the  watch  to  his  ear  ; while  the  individual 
who  has  been  gifted  with  a better  constituted  nervous  system  will 
make  out  many  other  particulars  that  escape  the  observation  of 
the  imbecile — e.g.,  the  smoothness,  the  weight,  the  dial  with  the 
circles  and  numbers,  etc.  Now,  if  all  these  features  are  represented 
in  different  areas  of  the  cerebral  cortex,  it  is  necessary  that  they 
be  closely  related  with  one  another  in  order  to  give  rise  to  the 
complete  image  of  the  watch,  since  there  concur  in  this  the  visual 
image  of  colour,  which  is  supplied  by  the  occipito-optic  system  ; that 
of  form,  which  depends  on  the  ocular  movements  ; the  tactile  image, 
if  the  hand  is  made  to  take  note  of  its  smoothness  ; the  muscular 
image,  if  the  hand  measures  its  size  and  appraises  its  weight  by 
suspending  it.  These  images  are  furnished  by  the  somaesthetic  and 
parieto-occipital  systems,  and  also  by  the  temporal  area  (the  tick- 
tack  of  the  watch).  Should  any  one  of  these  areas  fail  to  co-operate 
in  the  harmonious  work  of  the  others,  there  arises  in  consequence 
a defect  in  perception,  except  in  those  cases  of  compensatory 
hyperfunctionality  of  well-developed  areas  such  as  is  observed  in 
some  cases  of  deaf-mutism  and  congenital  blindness. 

Suppose  we  have  a patient  whose  mind  is  absorbed  by  an  emo- 
tional state,  full  of  fear  and  anguish,  as  in  melancholiacs,  or  by  a 

13—2 


196 


PSYCHIATRY 


delirious  idea  that  has  invaded  and  taken  sole  possession  of  the 
field  of  consciousness,  as  in  paranoics  ; in  such  a case  it  will  be 
difficult  for  fresh  impressions,  unless  of  great  intensity,  to  reach 
the  visual  point  of  consciousness,  and  to  direct  it  upon  the  objects 
whence  they  issue,  so  as  to  give  rise  to  normal  perception.  On 
the  contrary,  what  happens  more  frequently  is  that  the  slighter 
stimuli  are  not  noticed  at  all,  or  else  are  noticed  imperfectly,  and 
are  quickly  assimilated  by  an  altered  perceptive  process  (illusion) 
to  the  delirious  mental  content,  since  the  consciousness  in  the 
process  of  recognition  furnishes  only  those  active  images  that  refer 
almost  exclusively  to  the  delirious  ideas. 

Another  large  group  of  perceptive  defects  is  composed  of  those 
cases  in  which  destructive  foci  in  determined  seats  interrupt  asso- 
ciative or  afferent  paths,  or  suppress  the  function  of  a sensory  zone 
in  the  mechanism  of  the  cerebral  mantle,  and  also  those  others  in 
which  a slow  degenerative  process  puts  out  of  work  a progressively 
increasing  number  of  anatomical  components.  Let  us  picture  to 
ourselves  an  individual  in  whom  there  has  occurred  an  interruption 
of  the  associative  paths  between  the  auditory  and  visual  areas  (by 
a degenerative  or  destructive  process)  ; the  perceptive  process  will 
be  defective  in  both  areas,  and  more  especially  will  there  be  abolished 
the  perception  of  the  most  complex  facts,  as,  for  example,  that  oi 
speech  (subcortical  alexia).  When  the  nerve-cell  elements  of  the 
individual  sensory  areas  are  degenerated — and  under  this  condition 
the  conjunction  of  the  different  elementary  sensory  components 
whence  the  concrete  images  result  may  certainly  be  possible,  but 
the  images  themselves  are  not  formed  in  the  different  areas — the 
recognition  of  an  actual  object  is  no  longer  possible,  provided 
the  notion  existed  through  former  perception.  The  result  may 
also  be  an  incomplete  perception,  with  either  a false  or  erroneous 
judgment,  simply  because  the  perceptive  judgment  has  no  basis 
more  substantial  than  the  features  and  relations  of  the  objects,  real 
or  imaginary.  We  find  this  condition  very  often  in  paralytic 
dements,  in  patients  with  destructive  foci  in  the  brain,  etc. 

The  most  classical  example  of  defective  perception  arising  through 
interruption  of  the  associative  paths  is  furnished  by  that  form  of 
disturbance  of  speech  known  as  ccolalia.  Let  us  suppose  the  acoustic 
word-centre  to  be  in  relation  with  the  intellectual  field  by  means 
of  associative  paths,  as  pictured  in  Fig.  49.  If  such  a path  be  cut 
through,  the  verbal  image  of  the  word  pronounced  by  others  is 
formed  in  the  respective  centre,  but  not  being  able  to  reach  the 
intellectual  field  is  not  comprehended,  and  instead  the  nerve-wave 
turns  back  through  the  small  temporo-frontal  arc  and  puts  in 
vibration  the  cortical  motor  centre  of  speech.  In  this  case  the  words 
heard  are  repeated  without  being  understood  (parrot  language, 
ecolalia).  The  same  phenomenon  is  repeated  when  the  intellectual 
field  is  unable  to  furnish  the  mental  correspondent  to  the  phonetic 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


197 

images  of  speech,  as  is  often  observed  in  progressive  paralysis  and 
acute  dementia. 

A bilateral  lesion  of  the  cortex  of  the  occipital  lobes  (external 
aspect)  gives  rise  to  psychic  blindness  (objects  seen  but  not  recog- 
nised), with  dementia  (through  loss  of  the  visual  components  of  the 
intelligence).  A lesion  of  the  subcortical  afferent  bundle  of  the 
auditory  centre  will  impede  the  arrival  of  the  auditory  waves  at 
the  perceptive  centre,  and  will  give  rise  to  subcortical  word-deafness 
(without  alexia  and  without  dementia).  On  the  other  hand,  a 
lesion  of  the  first  temporal  convolution,  if  on  both  sides,  will  give 
rise  to  suppression  of  auditory  perception,  or,  if  only  that  on  the 
left  side  be  injured,  of  speech  alone.  Word-deafness  may  be  defined, 
whatever  upholders  of  a twofold  centre  may  think,  as  the  suppres- 
sion of  the  auditory  perception  of  speech. 

A great  difference  in  perceptive  capacity  is  found  even  among 
sane  persons.  The  power  of  summing  up  the  greatest  possible 
number  of  qualities  and  relations  in  a perceptive  unit  of  time,  given 
the  greatest  number  of  aspects  under  which  each  object  and  each 
position  can  be  regarded,  is  the  surest  foundation  of  what  we  call 
intelligence,  and  this  is  associated  with  another  factor — the  time 
of  perception  with  discrimination.  We  meet  with  individuals  who 
are  certainly  capable  of  perceiving,  who  possess  the  means  and 
the  aptitude  to  receive  all  gradations,  modes  and  forms  of  stimuli, 
or  the  circumstances  of  a given  position,  besides  all  the  relations  of 
individual  objects  with  others  analogous  (recognition  and  dis- 
crimination), and  all  those  relations  established  between  the  objects 
on  the  one  hand  and  the  various  subjective  positions  on  the  other, 
according  to  the  laws  of  association  in  time  and  space — yet  such 
individuals  require  a long  time  for  the  perception,  discrimination, 
and  judgment  of  the  facts  and  their  relations. 

I am  familiar  with  individuals  who  notice  immediately  any  new 
and  variable  positions,  any  new  relations  to  the  environment,  and 
who  judge  with  extraordinary  lucidity  and  rapidity,  and  operate 
according  to  the  laws  of  adaptation.  There  are  others,  however, 
who,  while  certainly  capable  of  comprehending  these  same  rela- 
tions, take  a longer  time  to  discriminate,  so  that  frequently  they 
adapt  themselves  to  the  new  condition  when  it  is  too  late  to  turn  it 
to  their  advantage.  We  have  here  to  deal,  not  with  a true  deficiency, 
but  with  a slowness.  This  condition  makes  itself  very  manifest 
in  many  psychopathic  states. 

It  is  easy  to  foresee  how  difficult  it  may  be  to  distinguish  the 
time  of  perception  from  that  of  reaction  in  an  experimental  research, 
since  we  can  only  estimate  perception  by  reaction.  A wide  know- 
ledge of  men  enables  us  to  distinguish  well  those  two  moments  of 
a complex  psychic  process.  There  is  no  doubt  that  many  indi- 
viduals, confronted  by  somewhat  complicated  positions,  do  not 
have  a clear  appreciation  of  them  till  after  a considerable  time, 


198 


PSYCHIATRY 


although  then,  and  then  only,  a rapid  action  follows,  but  is  in  con- 
sequence tardy,  and  hence  less  efficacious.  There  are  others,  again, 
who  find  an  obstacle  in  the  action,  even  when  they  have  had  for 
some  time  a clear  perception  of  a given  position.  There  is,  accord- 
ingly, a great  difference  in  perceptive  capacity  among  men,  and  it 
is  certain  that  under  equal  conditions  those  who  most  rapidly  and 
clearly  perceive  their  relations  to  the  environment  and  adapt  them- 
selves thereto  have  the  most  success  in  life. 

There  is  no  lack  of  very  instructive  experiments  bearing  upon 
this  question.  All  experimenters  have  noted  great  differences  in 
the  time  of  perception  in  the  same  individual  at  different  times 
and  in  various  subjects.  In  addition  to  external  circumstances, 
Morselli  has  enumerated  certain  subjective  ones  that  modify  the 
time  of  reaction.  Of  these  the  greatest  influence  is  exercised  by 
the  following  : the  expectant  attention,  the  engaged  attention,  the 
precognition,  distraction,  fatigue,  exercise,  the  action  of  stimu- 
lants, the  physical  state,  and  others. 

t ^ Tambroni  and  Algeri,  in  the  Institute  of  Reggio-Emilia,  obtained 
mean  times  of  reaction  to  the  twofold  tactile  perception  from  a 
minimum  of  0-174  of  a second  to  a maximum  of  0-196  in  sane  per- 
sons. These  figures,  expressing  means,  varied  greatly  in  the 
experiments  upon  the  mentally  afflicted.  In  maniacal  exaltation 
they  were  found  to  be  longer — from  0-218  to  0-404 ; in  lipemania, 
from  0-278  to  0-548.  In  states  of  mental  enfeeblement  the  time 
of  reaction  was  proportionately  longer  than  the  normal — from 
0-326  to  0-395.  In  epileptic  insanity  the  mean  ranged  from  0-271 
to  0-508  ; the  highest  was  given  by  those  individuals  in  whom  there 
was  reason  to  believe  that  the  morbid  process  had  already  damaged 
the  mental  faculties.  In  paranoia  a lower  mean  was  found  than  in 
the  normal  state  (0-124),  while  the  others  approached  to  the  normal. 
In  mental  affections,  then,  the  time  of  perception  and  of  reaction 
becomes  for  the  most  part  lengthened.  No  less  interesting  were 
the  experiments  of  Tanzi  and  Guicciardi  on  the  time  of'  acoustic 
reaction  in  healthy  individuals,  and  in  those  with  hallucinations  of 
hearing.  The  mean  of  the  smallest  group  of  the  latter,  as  com- 
pared with  the  mean  of  the  smallest  group  of  normal  individuals, 
was  as  54-7  to  101-2  thousandths  of  a second.  This  denotes  that 
the  acoustic  sensory  centre  in  paranoics  possesses  a higher  potential 
than  the  normal.  In  the  largest  group,  again,  the  mean  was  about 
125-9  thousandths  of  a second  in  healthy  persons,  and  about  140-3 
in  paranoics.  The  observers  attributed  this  to  the  lesser  capacity 
of  paranoics  for  a constant  extensive  attention  (Rivista  sper.  di 
Frcn.,  1884-1885). 

Tardy  reaction  is  characteristic  of  all  states  of  mental  enfeeble- 
ment and  fatigue  (dementia,  phrenasthenia,  neurasthenia,  hysteria), 
or  is  a result  of  depressing  emotions  (grief,  fear,  preoccupations),  as 
in  melancholia. 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


199 


Illusion. — Another  disorder  of  perception  is  the  so-called 
illusion.  This  is  a qualitative  disturbance,  and  it  is  as  well  to 
give  as  precise  an  explanation  of  it  as  possible.  An  individual 
who  judges  an  object  differently  from  what  it  is,  is  a subject  of 
illusion. 

An  illusion  consists  in  a disorder  of  perception  by  which  the 
subject  reproduces,  in  the  object  present,  features  that  do  not 
correspond  to  the  reality,  but  which  are  reawakened  by  an  altered 
associative  mechanism  and  by  an  anomalous  tension  of  certain  nervous 
apparatus.  Such  a representation  necessitates  the  action  of  an  objec- 
tive stimulus. 

If  an  individual,  perceiving  a cloud,  believes  he  sees  Christ,  or  the 
Madonna,  or  an  angel,  and  describes  the  attitude,  the  movements, 
the  physiognomy,  recognising  therein  the  features  of  the  image 
which  he  has  formed  for  himself  of  Christ,  or  of  the  Madonna,  or 
an  angel,  he  is  an  illuded  person.  A requisite  condition  to  the 
correct  definition  of  illusion  is  that  there  be  a cloud,  or,  speaking 
generally,  an  object  that  gives  rise  to  the  impression  from  without, 
and  a mental  content  at  high  tension  with  which  the  objective 
nerve-wave  mingles  and  blends. 

Illusion  is  often  confused  with  error,  with  which  it  has  many 
points  in  common.  If,  in  a state  of  distraction,  one  sees  a cloud  and 
judges  it  to  be  something  else  that  may  bear  a certain  relation  to  a 
given  order  of  ideas  which  at  the  moment  is  predominant  in  his 
mind,  then  he  shall  have  committed  an  error  of  judgment,  which  is 
corrected  immediately  his  attention  is  turned  to  the  vague  sensation 
that  has  broken  in  upon  his  train  of  thought. 

If  some  night,  as  we  are  going  along  a lonely  road,  overcome  by 
fear  and  apprehension  lest  evil-disposed  persons  surprise  us,  we  hear 
a noise,  a slight  trampling,  or  the  simple  rustling  of  plants,  and  there 
arises  within  us  the  thought  of  the  assassin,  this  is  an  idea  correlative 
to  that  special  emotion  with  which  a determined  group  of  images 
is  closely  bound.  Such  a fact  is  still  not  an  illusion  ; but  if,  in  a 
small  plant,  or  a branch  shaken  by  the  wind,  or  the  rustling  foliage, 
we  recognise  the  assassin,  this  is  an  illusion.  The  illusion  must 
furnish  to  the  existing  object  the  subjective  features  previously 
perceived  in  the  external  world,  or,  in  other  words,  preformed.  Here 
we  are  dealing  with  previous  psychic  formations  reproduced  by  the 
law  of  association  each  time  there  exists  outside  us  a fact  that  takes 
the  form  of  an  elementary  sensation  common  to  many  psychic 
products  of  diverse  nature.  It  is  evident  that  in  such  a case  the 
elementary  sensation  gives  rise  in  the  field  of  perception  to  that  pre- 
formed mental  product  which,  either  permanently  or  incidentally, 
has  assumed  the  strongest  associative  relations  with  the  elementary 
sensation.  When  a superstitious  person  passing  by  a cemetery 
at  night  pictures  to  himself  spirits  in  the  most  varied  forms,  he  puts 
himself  in  the  most  favourable  conditions  for  recognising  one  of 


200 


PSYCHIATRY 


these  figures  in  a tree,  a pile  of  stones,  or  a dog.  This  common  point 
of  elementary  sensation,  that  can  be  associated  with  the  most  varied 
reproducible  psychic  formations,  is  what  James  calls  a ^thing.’’ 
Suppose  a ‘thing’  common  to  four  systems,  a,  b,  c,  d (Fig.  56) ; its 
orientation,  once  solicited  by  an  external  stimulus,  will  be  towards 
b or  towards  c if  by  any  chance  whatever  there  be  determined  in 
b or  c d.  stronger  reproductive  tension  independent  of  the  sensational 
stimulus  of  the  ‘ thing  ’ {i)  coming  into  action.  Sometimes  such 
associative  ties  seem  to  surprise  the  consciousness,  but  in  this  case 
we  must  admit  the  existence  of  some  old  ones  that  have  passed  into 
unconsciousness,  and  instantaneous  formations  arising  through  the 
most  diverse  morbid  conditions.  Etror  of  the  senses  examined  in 
this  respect  is  rather  error  of  the  intellect.  The  illusions  produced 
by  the  expectant  attention,  especially  if  accompanied  by  emotional 
states,  are  explained  precisely  on  the  ground  that  the  mind  is,  for 


(? 


the  time  being,  full  of  the  thought  of  that  object.  The  illusions  of 
the  ascetics  who  have  seen  the  head  and  eyes  of  an  image  moving  ; 
those  of  jealous  individuals  who  are  always  on  the  alert  as  regards  the 
subject  of  their  jealousy  ; those  of  some  spiritists  to  whom  have 
been  suggested  the  phenomena  that  have  now  aroused  their  intense 
curiosity — such  are  the  most  common  examples  presented  to  us  by 
daily  experience  outside  the  field  of  pathology.  All  the  senses  furnish 
material  for  illusions,  which  are  simple  or  sensory,  and  complex  or 
perceptive,  as  well  as  physiological  and  pathological.  Among 
the  examples  of  simple  or  sensory  and  physiological  illusions  is  that 
produced  by  Aristotle’s  experiment,  which  consists  in  crossing  the 
index  and  middle  fingers  in  such  a way  that  the  inferior  margin  of 
the  pulp  of  the  latter  overlies  the  upper  margin  of  that  of  the  index, 
and  in  this  position  taking  hold  of  and  turning  a small  body,  such 
as  a pea,  between  the  two  fingers,  when  there  will  seem  to  be  two 
instead  of  one.  There  will  be  the  sensation  that  the  contact  with 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


201 


the  index  takes  place  above  instead  of  below,  and  vice  versa  in  the 
case  of  the  middle  finger  ; and  the  single  object  touching  them  will 
seem  to  be  in  two  places. 

If,  during  a railway  journey,  the  train  in  which  we  are  travelling 
stops  at  a station,  and  meanwhile  another  train  arrives,  the  slow 
movement  of  the  latter,  observed  from  within  the  carriage,  gives 
us  the  illusion  that  our  train  is  moving,  while,  on  the  contrary,  it 
is  at  a standstill.  The  explanation  is  that  the  succession  of  the 
images  of  the  passing  train  on  the  retina  reawakens  all  those  states 
and  those  other  sensations  that  had  taken  place  until  a few  moments 
before,  while  the  train  was  in  motion. 

We  may  have  a very  large  number  of  physiological  illusions — 
and  they  are  common  to  all  men — especially  those  of  geometrical 
figures  and  even  of  sounds.  These  forms  of  illusions  have  been 
the  object  of  experimental  researches  in  recent  times  (Knox, 
M.  Binet,  Thiery,  Heymans).  Thus,  for  example,  two  lines  of 
equal  length  seem  unequal,  two  parallel  lines  seem  to  converge  or 
diverge,  angles  perfectly  equal  seem  unequal.  We  may  take  the 
measure  of  these  illusions  by  drawing  other  lines  establishing  the 
parallelism  of  the  lines  or  the  equality  of  the  angles.  We  obtain, 
as  a result,  differential  angles  that  represent  the  amplitude  of  the 
illusion. 

Thiery  distinguishes  three  groups  of  geometrical  visual  illusions — 
those  of  direction,  size,  and  curvature.  Zollner’s  figure  gives  the 
illusion  of  perfectly  parallel  lines  seeming  otherwise.  Each  of  the 
parallel  lines  is  cut  at  an  acute  angle  by  small  transverse  lines 
parallel  with  one  another,  and  disposed  in  such  a way  that  the 
transversals  of  neighbouring  lines  have  an  opposite  direction 

(Fig.  57). 

Zollner’s  apparatus  (for  the  particulars  of  which  I refer  to  the 
original)  gives  an  illusion  regarding  straight  vertical  lines  and  the 
respective  angles  with  horizontals  that  cut  them  at  a right  angle. 
The  four  principal  lines  which  give  rise  to  the  illusion  are  30  centi- 
metres long,  4 millimetres  broad,  and  6 centimetres  distant  from 
each  other.  A quadrant  placed  at  the  side  enables  one  to  read 
the  angle  that  the  principal  lines  make  with  one  another.  The  four 
vertical  lines,  and  especially  the  two  central,  seem  bent,  while 
they  are  in  reality  straight  (Fig.  57). 

An  analogous  illusion  is  produced  by  the  disposition  given  to 
the  lines  by  the  same  Zollner,  and  depicted  in  Fig.  58.  Here  we 
have  a number  of  parallel  lines,  each  of  which  is  cut  by  transversals 
at  an  acute  angle.  These  transversals  are  parallel  with  one  another. 
Given  this  disposition,  the  first  lines  appear  not  to  be  parallel. 

An  example  of  an  illusion  of  size  is  given  in  Fig.  59.  The  illusion 
arises  from  the  influence  that  figures  or  lines  of  different  size  exercise 
upon  one  another.  The  lines  a,  b,  and  afi  are  of  the  same  length, 
yet  a,  b,  placed  between  two  short  lines,  seems  smaller  than  a^, 


202 


PSYCHIATRY 


placed  between  two  longer  lines.  This  would  appear  to  be  an 
effect  of  confluence  (Mueller-Lyer). 

Analogous  illusions  occur  with  regard  to  weights.  When 
bodies  of  different  volume  but  of  identical  weight  are  placed  side 
by  side  (experiments  of  E.  J . Seashore,  ‘ Measurements  of  Illusions 
and  Hallucinations  in  Normal  Life,’  1895),  and  are  then  raised, 
one  after  the  other,  in  order  to  estimate  their  weight,  the  larger 


bodies  always  seem  heavier.  The  illusion  is  stronger  when  the 
gaze  is  fixed  directly  on  the  bodies  as  they  are  being  weighed.  Here 
we  have  the  influence  of  the  volume  over  the  weight,  inasmuch 
as  we  associate  weight  with  volume,  and  provide  for  larger  volumes 
a greater  muscular  effort  and  a higher  image  of  weight,  while  for 
smaller  bodies  we  call  into  play  a less  amount  of  muscular  effort 
and  a lower  image  of  weight. 

It  is  a phenomenon  of  preperception  or  expectant  attention,  the 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


203 


influence  of  which  is  well  proved  by  the  experiments  of  Grutzner. 
The  observer  is  shown  a series  of  images  on  the  stroboscope  repre- 
senting children  playing  at  leapfrog.  At  a given  moment  another 
series  is  made  to  pass  in  the  stroboscope,  the  figure  of  the  child 
in  the  act  of  leaping  being  now  covered  with  white  paper,  and  the 
observer,  if  not  warned  beforehand,  believes  he  continues  to  see 
the  one  child  leap  over  the  back  of  the  other. 

Dresslar  reports  the  following  additional  experiment  : Two 


5 

§ 

5 


s i 


5 


$ 


? 5 


h s 


5 


i * 

\ 


I 


Fig.  58. 


straight  lines  are  made  on  a card  by  means  of  successive  pin-pricks, 
and,  meeting,  cut  one  another.  The  finger  is  then  made  to  run  over 
one  of  the  two  lines  approximating  it  to  the  point  where  they 
intersect.  At  this  point  the  two  portions  of  the  second  line  are  not 
noticed  simultaneously,  but  first  the  half  of  the  oblique  forming 
an  acute  angle  with  the  line  followed,  and  then  that  portion  forming 
an  obtuse  angle  with  it,  so  that  the  latter  is  felt  as  if  it  were  placed 


a 


b 


h' 


Fig.  59. 

beside,  instead  of  being  a prolongation  of  the  other.  An  important 
fact  has  been  brought  to  light  by  A.  Binet  and  by  Biewliet — 
namely,  that  illusions  are  stronger  and  more  frequent  in  children 
than  in  adults,  a fact  which  serves  to  form  some  personal  equations 
with  the  perceptive  power. 

There  exist  further  illusions  by  suggestion  which  may  frequently 
be  an  auto-suggestion,  as  occurs  when  we  propose  to  demonstrate 
to  ourselves  a preconception,  and  occurs  still  more  frequently 


204 


PSYCHIATRy 


in  young  microscopists,  who  are  induced  by  the  authority  of  their 
professor  to  see  through  the  microscope  many  particulars  that 
have  no  existence  for  their  eyes  except  in  so  far  as  described  to  them 
by  the  professor. 

If  we  pass  now  from  what  I would  call  the  physiological  field 
to  the  study  of  the  distinctly  pathological  illusions,  we  find  an 
almost  complete  observance  of  the  law  that  the  illusion  arises  from 
preperception,  a fact  that  is  verified  in  all  those  cases  in  which  a 
group  of  coloured  and  active  ideas,  associated  with  emotional  states 
with  which  they  are  normally  in  relation,  fill  the  consciousness  with 
all  the  sensory  images  that  serve  in  normal  life  to  nourish  and  revive 
the  thought  in  question. 

Paranoics  afford  the  most  frequent  example  of  this.  The  poor 
persecuted  individual,  overcome  by  the  conviction  of  the  dangers 
to  which  the  wickedness  of  others  subject  him,  loads  his  mind 
with  enemies,  sees,  in  the  physiognomy  of  the  people  with  whom 
he  comes  in  contact,  the  signs  of  derision,  of  scorn,  of  contempt,  and 
menace. 

The  paranoic  lover  sees  in  the  movements  of  an  indifferent 
lady,  who  is  behind  the  window,  the  assurance  of  love  which  the  lady 
exchanges  with  him  unawares,  or  he  discerns  it  in  the  smile  bestowed 
on  him  as  she  is  passing  in  her  carriage,  thus  giving  him  a right 
to  run  after  her  in  order  to  manifest  the  love  that  is  consuming 
his  soul. 

The  girl  who  is  preoccupied  with  the  beauty  of  her  figure,  of 
the  possible  defects  of  which  she  has  a horror,  finds  such  defects 
in  the  distorted  mouth,  the  asymmetrical  face,  the  round  eyes,  the 
contorted  nose,  while  admiring  herself  in  the  looking-glass.  The 
suspicious  and  jealous  husband  who  watches  all  the  movements 
of  his  wife,  whom  he  supposes  an  adulteress,  sees  in  her  innocent 
glances  or  in  her  honest  salutation  to  another  man  the  irrefutable 
proof  of  adultery,  and  plans  to  get  rid  of  her  by  killing  her.  The 
persecuted  individual  who  is  afraid  of  being  poisoned  believes 
that  he  perceives  the  presence  of  copper  or  arsenic  in  the  salt 
taste  of  his  food,  and  if  he  hears  some  voices  from  afar,  decides 
that  they  are  raised  against  him  by  people  who  are  plotting  his 
destruction. 

Some  visual  illusions  of  size  may  be  of  peripheral  origin  and  in 
reality  muscular.  I have  referred  to  the  case  of  a young  man 
who,  on  seeing  his  brother  after  a long  absence,  was  surprised  to 
find  him  very  small  in  stature.  Another  patient  in  my  clinique 
saw  his  horses  small  and  lean,  and  was  grieved  thereat.  Here  we 
have  the  muscular  element  of  perception  coming  into  play,  and  there 
is  no  reason  to  reject  the  idea  that  the  defect  ma\'^  be  in  the  peripheral 
apparatus. 

Further,  we  have  tactile  and  muscular  illusions  occurring  even 
in  amputated  limbs,  in  illustration  of  which  observations  have 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


205 


been  made  by  Weir  ^litchell,  Lemos,  Rizet,  Charcot,  Abbatucci, 
and,  more  recently,  in  a very  interesting  article,  by  A.  Pitres.  We 
have  here  the  persistent  sensation,  in  some  cases,  of  the  existence 
of  the  lost  limb  ; kincesthetic  sensations,  sometimes  painful, 
referred  to  parts  of  the  body  that  have  been  amputated  for  some 
time  ; momentary  sensations  in  the  'phantom  limb  by  exciting  the 
corresponding  nerve  plexus  with  electricity,  as  in  the  case  that 
came  under  Weir  Mitchell,  who  describes  the  great  surprise  of  the 
patient,  whose  shoulder  he  had  disarticulated  some  time  before,  and 
who  cried  under  the  stimulation,  ‘ Oh,  my  hand,  my  hand  !’  Occa- 
sionally there  are  illusory  voluntary  movements  of  the  phantom 
limbs,  as  sometimes  provoked  by  excitation  of  the  nerves  of  the 
stump.  All  these  illusory  sensations  of  those  who  have  suffered 
amputation  are  due  most  frequently  to  excitation  of  the  nerve- 
filaments  in  the  cicatrices,  which  reawaken  old  images  in  the  re- 
spective centres,  or  determine  their  formation  by  association  in  the 
field  of  the  consciousness. 

One  phenomenon  that  may  be  placed  among  the  illusions  is  that 
which  goes  under  the  name  of  coloured  audition.  In  Italy  interesting 
observations  upon  it  have  been  published  by  Lussana,  Verga, 
Ughetti,  Mendoza,  Mirto,  D’Abundo,  and  others.  It  is  very  common 
amongst  healthy  persons  (about  20  per  cent.)  and  blind  persons, 
but  is  much  more  frequent  in  the  blind  who  once  had  vision  than 
in  those  who  never  possessed  it.  This  condition  is  found  in  12  per 
cent,  of  the  blind  at  the  most  (Philippe).  The  phenomenon  con- 
sists in  the  reawakening  of  a colour  under  the  acoustic  impression 
of  vowels,  words,  or  sounds  of  instruments.  Sometimes  the  colour 
is  provoked  by  touch  (the  form  of  an  object).  This  last  phenomenon 
is  met  with  in  some  blind  persons  in  the  case  of  things  they  have 
never  seen,  while  it  is  absent  in  the  case  of  things  they  have  seen 
and  the  memory  of  which  they  preserve. 

The  phenomenon  is  not  easily  interpreted,  but  as  there  is  no 
constant  feature,  and  as  each  of  those  who  exhibit  the  phenomenon 
affords  an  example  of  diverse  associations,  we  must  deduce  from 
this  that  it  is  principally  a fact  of  association.  For  example,  some- 
times the  sound  rearouses  the  colour  of  the  instrument  producing 
it ; at  other  times  it  is  the  earliest  associations  that  have  arisen  in 
infancy  during  the  rapid  evolutionary  progress  of  the  mind.  A 
servant  of  the  author,  like  all  the  common  people  in  Italy,  used 
to  call  turchino  (azure)  blu  (blue).  Since  then,  the  vowel  i of  the 
accented  syllable  of  the  word  turchino  has  always  made  the  author 
see  blu,  as  0 makes  him  see  rosso  (red),  and  u nero  (black),  vulgarly 
nero-fumo  (soot).  In  this  case  the  association  of  the  vowel-sound 
with  the  colour,  during  the  period  of  mentaP' formation,  is 
evident. 

The  diphthongs  evoke  the  colours  of  the  two  vowels  forming 
them.  The  strongest  combinations  are  found  between  words  and 


2o6 


PSYCHIATRY 


colours,  and  the  fact  that  the  same  word  or  vowel  arouses  different 
colours  in  different  individuals,  and  that  the  opposite  word,  as 
in  a case  of  D’Abundo,  gives  sometimes  the  contrary  colour  and 
at  other  times  the  same  colour,  confirms  the  idea  of  the  accidental 
association. 

•Accordingly,  it  is  caprice  or  chance  that  establishes  certain 
associations  between  sounds  and  colours. 

Another  sensory  disorder  of  a more  serious  nature,  which  at 
bottom  is  closely  related  to  the  true  illusion,  if  indeed  it  may  not 
signify  the  same  thing,  is  hallucination.  A hallucination  is  a sub- 
jective perception.  While  in  the  case  of  the  illusion  it  is  the  object 
that  is  badly  perceived,  because  the  subject  furnishes  it  with  the 
features  of  which  the  consciousness  is  full,  and  which  do  not  belong 
to  it,  in  hallucination  the  external  stimulus  is  absent  to  begin  with, 
and  the  reproduction  originates  primarily  in  the  sensory  centres 
from  images  which  have  perhaps  at  some  former  time  been  formed 
and  registered  in  their  respective  centres.  These  images,  however, 
may  result  from  features  furnished  by  various  sensations  at  different 
times,  and  now  associated  together  by  the  creative  power  of  the 
brain  in  a concrete  image  in  the  same  sensory  areas  in  which  images 
are  formed  and  registered  by  a physiological  process  ; here  these 
become  rearoused  by  an  intrinsic  activity  of  the  nerve-elements, 
and  are  projected  outside,  or,  as  it  is  said,  objectivated. 

All  sensations  leave  a residuum,  a trace  which  we  call  an  image, 
and  we  think  and  operate  with  the  concurrence  of  all  the  more  or 
less  apparent  mental  capital  of  images  that  have  gone  on  accumu- 
lating, and  are  always  capable  of  being  reawakened  and  represented, 
in  order  to  become  associated  with  the  new  material  that  the  brain 
receives  and  assimilates  from  the  external  world.  If  we  are  making 
our  way  towards  a known  locality,  we  picture  to  ourselves  the 
route,  the  difficulties  to  be  overcome,  and  the  places  through  which 
we  have  to  go  ; if  we  are  preparing  to  go  to  hear  a grand  opera  of 
which  we  are  fond,  numerous  images  of  former  spectacles  come  up 
before  us,  and  the  most  stirring  movements  of  the  score  are  called 
to  mind  ; if  we  are  preparing  to  deliver  a lecture,  our  mind  repre- 
sents to  itself,  in  the  quietude  of  its  dominions,  the  words  and  phrases 
that  give  precise  form  to  the  fundamental  thought  of  the  lecture. 
In  pathological  cases,  the  reawakening  of  the  images  is  much  more 
intense  and  mucli  more  vivid,  so  much  so  that  they  become  projected 
externally  as  true  actual  sensations,  which,  though  resulting  from 
a subjective  process,  are  referred  to  an  object  present 

The  product  of  the  hallucination,  observed  externally,  as  though 
the  object  wdiich  it  represents  had  existence,  surprises  the  conscious- 
ness. Even  whthin  physiological  limits  w'e  hnd  a diversity  in  the 
degree  of  vividness  of  the  images.  Artists,  for  example,  possess 
the  faculty  of  representing  to  themselves  in  an  especial  degree  colours 
of  the  sensory  images.  It  is  not  an  uncommon  thing  for  a painter 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


207 


or  a sculptor  to  produce  a lifelike  reflection  of  the  figures  that  he 
wishes  to  reproduce  on  the  canvas  or  in  the  marble,  as  though 
actually  seen,  while  in  the  generality  of  men  the  memories  are  less 
vivid  and  more  intellectual. 

One  of  the  most  distinguished  and  esteemed  Italian  artists,  who 
was  for  some  time  a patient  in  the  asylum  at  Naples  in  1883,  when 
engaged  in  painting  or  drawing  a portrait,  used  to  take  up  his  position 
at  a distance  of  4 or  5 metres  in  front  of  the  canvas  and  there  prepare 
his  brush  and  colours,  from  time  to  time  casting  an  acute  and  pene- 
trating glance  at  the  canvas,  as  though  he  wished  to  find  in  it  the 
point  of  accommodation  of  his  eyes  in  order  to  reveal  the  image 
which  he  almost  saw  projected  upon  it  ; he  would  then  grasp  his 
brush,  run  towards  the  canvas,  and  execute  three  or  four  rapid 
strokes  after  the  manner  of  a fencer,  then  he  would  suddenly  retire 
again,  and  the  process  would  be  repeated  as  before.  In  this  way, 
after  seven  or  eight  assaults,  the  figure  was  beautifully  delineated, 
and  already  it  seemed  as  though  a breath  of  life  were  infused  into, 
and  came  potent  from,  those  formless  colours. 

Cases  of  isolated  hallucinations  are  found  in  individuals  who 
present  no  other  morbid  manifestations,  and  who  at  the  most  may 
be  considered  neuropathic.  I am  compelled  to  regard  as  untrue, 
or  at  least  as  greatly  exaggerated,  the  results  of  the  statistical 
inquiry  of  Edmund  Gurney,  who  says  that  in  every  ten  persons 
there  is  certainly  one  who  has  had  at  one  or  another  time  in  his  life 
a true  hallucination.  This  proportion  is  not  attained  unless  we 
enumerate  infants  and  children  amongst  the  persons,  and  include 
the  hallucinations  that  occur  during  sleep  (hypnogogic).  On  the 
other  hand,  it  would  be  well-nigh  impossible  to  calculate  amongst 
the  number  the  dreams  that  are  prolonged  for  some  time  into  the 
waking  state.  It  is  certainly  true  that  many  healthy  and  highly- 
talented  men  have  had  a hallucination  at  one  time  or  another. 
The  hallucination  of  which  I am  speaking  differs  from  pathological 
hallucinations  in  this  respect,  that,  in  the  healthy  individual — often 
highly  intelligent — in  whom  the  process  of  ideation  takes  place 
normally,  the  personality  offers  resistance  and  maintains  its  integrity, 
so  that  the  recognition  of  the  pathological  fact  is  prompt.  Andral, 
when  a student  of  anatomy,  was  profoundly  impressed  by  the 
condition  in  which  he  found  a cadaver,  lying  dismembered  and  in 
process  of  putrefaction,  in  the  dissecting-room.  While  taking  a 
walk  in  the  evening  he  saw  the  cadaver  and  felt  its  stench  ; he 
recognised,  however,  that  it  was  a physiological  fact,  and  attributed 
it  to  the  vivid  impression  that  the  sight  of  the  cadaver  had  made 
upon  him. 

Hallucinations  were  more  frequent  in  olden  times  than  at  the 
present  day,  yet  there  is  no  lack  of  quite  recent  examples. 

Quintus  Curtius  Rufus,  while  walking  one  evening,  saw  a 
lady  of  extraordinary  height  and  beauty,  who  told  him  she  was 


208 


PSYCHIA  TRY 


Africa,  and  that  one  day  he  would  become  Proconsul  in  that 
country. 

The  Christian  religion  owes  not  a little  of  its  triumph  to  the 
hallucination  of  Constantine,  who,  when  marching  towards  Rome 
at  the  head  of  his  army,  saw  a flaming  cross  above  the  disc  of  the 
sun  with  the  inscription,  in  Greek  characters,  iv  tovto)  vtKa — in 
hoc  {signo)  vinces. 

Spinoza  tells  how,  awakening  at  daybreak  one  morning  from  a 
profound  sleep,  the  images  that  he  had  seen  in  a dream  reappeared 
before  him  with  such  vividness  that  it  seemed  to  him  they  had  been 
real ; among  others,  the  figure  of  a Brazilian  negro  impressed  him, 
but,  he  said,  ‘ he  was  completely  unknown  to  me.’ 

It  is  recorded  by  Lombroso  that  Van  Helmont  declared  he  saw 
a guardian  angel  appear  to  him  in  all  the  most  important  circum- 
stances of  his  life. 

Savonarola  used  to  say  his  visions  were  true,  and,  among  other 
things,  asserted  that  he  had  seen,  in  the  sky,  a hand  grasping  a sword 
on  which  were  written  the  following  words  : ‘ Gladius  domini  super 
terram  citu  et  velociter  ’ (Pasquale  Villari). 

Cromwell,  while  lying  tired  and  sleepless  in  bed,  had  an  appari- 
tion of  the  gigantic  figure  of  a lady,  who  told  him  he  would  be  the 
greatest  man  in  England. 

The  lamented  Andrea  Verga  described  to  the  author  the  hallu- 
cination he  had,  while  in  bed  one  night,  of  a skeleton  which,  lying 
at  some  distance,  commenced  to  move  in  the  direction  of  the 
bed  ; as  it  approached,  the  different  bones  separated  one  from 
another  and,  having  reached  the  bed,  clambered  over  the  bedclothes. 

Persons  with  hallucinations,  stories  of  whom  abound  in  all 
ancient  history,  and  especially  that  of  the  religions  (vide  the  recent 
publication  of  Schiattarella,  Miracoli  e Profezie,  1899),  may  be 
divided  into  three  categories.  The  first  is  composed  of  men 
whom  we  now  regard  as  delirious,  but  in  relation  to  their  own  times 
their  hallucinations  represented  the  dominant  ideas,  and  especially 
those  of  an  emotional  nature,  and  at  the  time  they  would  be  con- 
sidered at  most  as  subnormal.  A true  epidemic  of  such  hallucina- 
tions occurred  in  the  Middle  Ages,  which  were  eminently  emotional 
and  superstitious.  The  second  comprises  those  who  presented,  in 
addition  to  the  hallucinations,  other  symptoms  of  mental  affection, 
which,  as  a whole,  produced  a profound  alteration  of  the  person- 
ality. The  third  comprises  those  in  whom  the  phenomenon  was 
quite  solitary,  and  quickly  recognised  as  a fleeting  episode  (like  the 
hallucinations  of  Andral,  Cromwell,  Verga,  etc.).  The  true  patient 
of  modern  times  regards  as  real  that  which  is  the  result  of  excita- 
tion of  his  sensory  centres,  and  accepts  it  as  though  he  received  it 
from  the  external  world,  while  the  healthy  individual  soon  notices 
the  error,  and  does  not  assume  to  be  real  what  he  knows  to  be  a 
subjective  product. 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


209 


Hallucinations  may  in  consequence  be  as  numerous  and  of  as 
different  nature  and  content  as  are  the  images  that  are  fixed  in  the 
brain — and  all  the  possible  combinations  of  these  that  may  result 
from  a process  of  decomposition  and  recomposition  in  the  most 
varied  manner — and  as  are  our  different  senses.  There  are  visual, 
auditory,  olfactory,  gustator}^  tactile,  verbal,  kinfesthetic  hallu- 
cinations, and  so  on.  The  auditory  and  visual  hallucinations  are 
best  defined  and  most  powerful — the  former  perhaps  more  than 
the  latter — just  as  hearing  and  sight  exercise  a stronger  influence 
in  the  development  of  thought  than  smell,  taste,  and  touch. 

Different  degrees  of  hallucination  have  been  described,  and 
rightly  so. 

Anyone  who  has  experience  amongst  the  insane  knows  how 
various  the  intensity  of  the  hallucinations  may  be,  according  to 
the  mental  constitution  of  the  individual  and  the  form  of  the  malady. 
In  the  same  affection,  as  in  paranoia,  the  hallucinations  are  fre- 
quently less  intense  at  the  beginning  than  at  a more  advanced 
stage  ; they  are  the  so-called  pseudo-hallucinations.  So  also  is 
their  content  variable.  In  this  regard  it  is  to  be  noted  that  the 
patients  sometimes  complain  of  noises,  hissing,  whistling,  ringing 
of  bells,  and  rustling  in  the  head  ; later  on,  the  noises  assume  the 
character  of  human  voices,  and  then  of  words.  These  are  heard 
in  the  head  or  other  parts  of  the  body  as  internal  voices,  and  then 
we  speak  of  true  verbal  hallucinations,  which  are  the  same  senso- 
motor  and  acoustic  verbal  images  as  are  aroused  in  the  process  of 
internal  diction,  only  more  coloured  and  forcible  than  is  the  case  in 
physiological  internal  diction.  At  a further  stage  these  images 
are  projected  into  space,  though  yet  lacking  that  vividness  that  is 
characteristic  of  well-developed  hallucinations.  So  also  the  dis- 
tance is  variable.  Some  hear  the  words  close  to  the  ear,  some  at  a 
short  distance,  others  in  the  room,  or  behind  the  walls,  or  under  the 
floor  ; others,  again,  hear  them  at  a considerable  distance,  in  the 
streets,  etc. 

Sometimes  these  voices  or  words  are  observed  in  the  tongue,  in 
the  throat,  in  the  abdomen,  or  in  other  parts  of  the  body.  They 
are  the  so-called  psycho-motor  verbal  hallucinations  (Seglas,  Tam- 
burini,  and  others).  A female  patient  in  my  clinique,  an  old 
hypocrite,  has  for  many  years  heaped  imprecations  on  her  tongue 
and  prayed  and  supplicated  to  have  it  taken  from  her,  because  it 
says  so  many  unseemly  words  which  she  does  not  wish  to  say,  and 
which  are  in  contrast  with  the  moral  custom  of  her  whole  life.  They 
are  the  tacto-kinetic  images  of  the  centre  of  Broca,  which  are  pro- 
jected into  exactly  the  same  organs  accustomed  to  the  articulation 
of  speech.  The  interpretation  of  words  heard  in  other  parts  of 
the  body  is  more  difficult,  unless  one  is  willing  to  admit  a central 
irradiation  of  the  increased  potential  of  the  zone  of  language  into 
the  surrounding  somsesthetic  zone,  and  hence  an  associative  syn- 

14 


210 


PSYCHIATRY 


thesis  of  the  contributing  zones,  with  irradiation  of  two  different 
but  fused  products  and  resonance,  in  the  consciousness,  of  the  pre- 
dominant product,  which  is  speech,  with  distant  irradiation  into 
other  parts  of  the  body. 

In  my  opinion,  however,  we  have  not  always  in  those  cases  to 
do  with  kinaesthetic  verbal  hallucinations.  In  some  cases,  as  in 
the  above-recorded  woman,  whom  I have  always  under  observa- 
tion, the  sensations  in  the  tongue  and  other  parts  of  the  body  are 
associated  with  true  verbal  auditory  images  in  such  a way  that  I 
am  convinced  that  in  many  cases,  if  not  in  all,  we  have  to  deal  with 
mixed  kinsesthetic-auditory  hallucinations,  with  the  simultaneous- 
ness— incapable  of  analysis  by  the  patient — of  the  tactile  or  kin- 
aesthetic  sensation  and  of  the  voice  heard,  rather  than  with  true 
kinaesthetic  hallucinations. 

As  in  the  case  of  spoken  language,  so  also  we  may  observe  visual 
hallucinations  of  written  language  or  kiucesthetic-graphic  hallu- 
cinations, which  give  the  patient  the  conviction  of  having  written 
words  which  in  reality  were  not  written. 

The  hallucinations  are  sometimes  provided  with  a strong  excito- 
motor  power.  I shall  have  occasion  to  return  several  times  to  this 
phenomenon  in  the  third  part  of  this  work  in  dealing  with  various 
forms  of  psychoses.  At  this  point,  however,  I am  constrained  to 
mention  the  importance  of  the  fact,  and  to  impress  it  upon  the  mind 
of  the  reader  with  an  example  that  came  under  my  observation 
in  the  Villa  di  Salute  at  Palermo,  and  was  reported  in  my  lectures 
on  Frenosi  Sensoria  (Vallardi,  Milan,  1897).  The  following  is 
a brief  summary  of  the  history  of  the  patient  : 


Observation  i. — Ven.  G.,  from  Lercara,  age  lorty-three,  married, 
with  three  sons,  shoemaker,  uneducated,  Roman  Catholic.  He 
was  admitted  to  the  Villa  di  Salute  of  Palermo  in  May,  1899. 

A maternal  uncle,  frequently  homicidal,  committed  suicide  to 
escape  falling  into  the  hands  of  the  public  authorities,  against  whom 
he  defended  himself  for  a whole  night  ; a paternal  uncle  led  a 
solitary  and  eccentric  life  ; a brother  is  taciturn  ; his  mother  has 
lost  her  memory  at  eighty  years  of  age. 

His  mother  had  a bad  pregnancy  in  him,  and  gave  birth  to  her 
son  with  considerable  suffering.  He  showed  nothing  of  note  in  the 
earliest  years  of  his  life.  At  the  age  of  eleven  he  commenced  to 
work  in  the  sulphur  mines,  where  he  had  to  do  very  heavy  work 
with  inadequate  nutrition.  During  the  time  he  was  at  this  work — 
that  is,  till  about  twenty-five  years  of  age — he  does  not  appear  to 
have  been  the  subject  of  sexual  excess  or  abuse  of  tobacco,  nor  to 
have  been  a masturbator  to  any  great  extent.  After  marriage  he 
took  up  shoemaking,  and  he  then  appears  to  have  commenced  to 
drink  wine  in  large  quantities,  so  as  to  have  been  frequently  drunk. 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


2ir 


He  has  not  suffered  from  any  illnesses  of  importance  except  small- 
pox, at  about  the  age  of  ten.  He  is  of  a credulous  nature. 

He  gives  the  following  account  of  the  beginning  of  his  illness  : 
About  the  middle  of  April  he  was  offended  by  a lady,  who  called 
him  a drunkard.  Indignant  at  this,  he  hurled  abuses  at  that  lady 
in  return,  and  she  thought  it  well  to  avenge  herself  by  referring  the 
matter  to  four  local  peasants,  of  whom  Ven.  G.  was  so  much  afraid 
that  he  remained  hidden  in  his  own  house  for  three  days.  One 
of  these  nights,  the  devil  appeared  to  him  in  a dream  and  said  : 
‘ Take  your  choice  ; either  cut  off  your  right  hand  or  be  murdered 
by  the  four  men.’  In  order  not  to  lose  his  life  and  soul,  he  thought, 
still  dreaming,  that  he  would  content  himself  to  live  minus  one 
hand  ; then,  having  awakened,  he  continued  to  see  the  devil  beside 
him,  enjoining  him  to  cut  off  his  hand.  Terrified  by  the  vision,  he 
was  uncertain  whether  to  execute  the  order  or  not,  either  through 
the  inhibition  produced  by  fear  or  on  account  of  the  pain  he 
would  have  to  suffer.  He  raised  an  objection  to  the  diabolical 
vision,  from  which  he  received  a further  injunction,  with  the 
assurance  that  he  would  suffer  no  pain.  It  was  then  that  he  gave 
a look  to  an  old  saw,  ‘ and,  aided  by  the  devil  himself,’  to  use  his 
own  words,  he  sawed  off  his  hand  without  feeling  any  pain,  for  his 
arm  seemed  ‘ as  though  made  of  wood.’ 

As  soon  as  he  had  completed  the  mutilation  of  his  hand  he  felt 
pain,  and,  terrified  by  the  amount  of  blood  he  was  losing,  attracted 
attention  by  his  loud  shrieks.  A terrified  and  stuporous  state  was 
suddenly  established,  and  in  this  condition  he  w^as  conducted  to  the 
Villa  di  Salute. 


Notwithstanding  that  such  subjective  images  are  projected 
outside,  they  do  not  all  possess  a strong  emotional  power.  Many 
patients  are  almost  indifferent  to  their  hallucinations,  as  though 
they  had  a suspicion  of  the  sensory  error.  Those  forms  of  hallucina- 
tion correspond  to  those  of  Doctor  N.  L.,  of  whom  Kandinsky 
speaks.  For  the  clearer  understanding  of  the  reader,  I report  the 
case  as  given  in  James’s  book. 

‘Dr.  N.  L.  heard  one  day  suddenly  amongst  the  voices  of  his 
persecutors  (“coming  from  a hollow  space  in  the  midst  of  the 
wall”)  a rather  loud  voice  impressively  saying  to  him:  “Change 
your  national  allegiance.”  Understanding  this  to  mean  that 
his  only  hope  consisted  in  ceasing  to  be  subject  to  the  Czar  of 
Russia,  he  reflected  for  a moment  what  allegiance  would  be 
better,  and  resolved  to  become  an  English  subject.  At  the  same 
moment  he  saw  a pseudo-hallucinatory  lion  of  natural  size  which 
appeared  and  quickly  laid  its  fore-paws  on  his  shoulders.  He  had 
a lively  feeling  of  these  paws  as  a tolerably  painful  local  pressure 
(complete  hallucination  of  touch).  Then  the  same  voice  from  the 
wall  said  : Now  you  have  a lion — now  you  will  rule,”  whereupon 

14-2 


212 


PSYCHIATRY 


the  patient  recollected  that  the  lion  was  the  national  emblem  of 
England.„  The  lion  appeared  to  L.  very  distinct  and  vivid,  but 
he  nevertheless  remained  conscious,  as  he  afterwards  expressed 
it,  that  he  saw  the  animal,  not  with  his  bodily,  but  with  his 
mental  eyes.  Accordingly  he  felt  no  terror  even  though  he  felt 
the  contact  of  the  claws.  . . . Had  the  lion  been  a complete 
hallucination,  the  patient,  as  he  himself  remarked  after  recovery, 
would  have  felt  great  fear,  and  very  likely  screamed  or  taken 
to  flight.’ 

Sometimes  the  acoustic  verbal  images  of  the  thought  itself 
are  projected  outside,  in  such  a way  that  the  subject  hears  all 
that  he  himself  thinks,  repeated  in  speech. 

This  phenomenon  is  not  difficult  of  interpretation.  A few 
years  ago  I observed  a very  telling  example  of  it.  It  concerned  a 
young  Sicilian  who  consulted  me  several  times  by  letter,  then  came 
to  me  in  person,  and  remained  in  Naples  for  some  time.  He  was  of 
good  intelligence,  and  discussed  his  business  affairs  faultlessly.  For 
some  time,  however,  he  had  been  surprised  at  hearing  all  that  he 
thought,  like  a distant,  indefinite  echo.  By  degrees,  after  the  space 
of  a year  or  thereabouts,  the  echo  became  clearer  and  also  nearer  ; 
and  while  from  the  outset  he  was  almost  convinced  that  it  w’as  due 
to  a cerebral  phenomenon,  when  he  commenced  to  hear  the  words 
that  he  thought  uttered  distinctly  in  the  environment,  he  became 
greatly  preoccupied  and  unsettled,  from  the  fact  that  it  led  him  to 
the  conviction  that  other  people  knew  all  he  was  thinking. 

Urged  on  by  the  continuance  of  this  state  of  affairs,  which  w^as 
leaving  him  ever  briefer  periods  of  peace,  he  commenced  to  suspect 
that  other  people  had  found  a mode  of  reading  his  thoughts,  and 
had  even  the  audacity  to  repeat  to  him  the  words  with  which  he 
himself  clothed  them.  This  suspicion  made  him  very  irritable 
and  sometimes  threatening  towards  the  members  of  his  own  family. 

The  important  thing  to  note  in  this  case  is  that  for  a long  time 
he  preserved  normal  the  consciousness  of  the  malady,  understanding 
that  it  was  impossible,  or  almost  so,  that  others  could  read  his  mind, 
and  came  to  me  to  get  a reliable  confirmation  of  his  conviction  that 
the  phenomenon  was  not  a matter  of  wickedness  on  the  part  of 
others,  and  that  accordingly  it  must  have  been  morbid.  It  was  only 
when  all  methods  of  treatment  seemed  useless  that  he  formed  the 
false  conception  that  other  people  were  ‘ stealing  his  thoughts.’ 

Hallucinations  are  frequent  phenomena  of  sleep.  It  has  been 
remarked  that  during  sleep  the  activity  of  the  brain  continues,  and 
images  follow  images,  and  scenes  follow  scenes,  often  without  order 
and  with  weak  associative  ties,  withdrawn  from  the  restraints  of 
logical  succession  in  time  and  space.  During  sleep  the  ego  no  longer 
offers  any  obstacle  to  the  uncurbed  imagination,  as  it  does  when  in 
relation  with  the  external  world. 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


213 


Thought,  during  sleep,  resembles  the  dream  that  a man  some- 
times has  in  his  ecstasy  when  awake.  An  example  of  this  state 
(besides  the  large  number  that  one  may  find  in  Mantegazza,  ' Le 
estasi  umayie')  is  afforded  by  the  ecstasy  of  Luther.  ‘ On  the  day 
of  Friday,’  says  Luther,  ‘ I was  in  my  room  engaged  in  a fervid 
prayer,  and  I was  contemplating  in  my  mind  how  Christ  was  nailed 
to  the  cross,  and  how  He  suffered  and  died  for  our  sins.  There 
appeared  to  me  on  the  wall  a brilliant  image  of  Christ,  with  its  eyes 
fixed  upon  me  as  if  it  were  the  Saviour  Himself.  I reflected  that  it 
was  an  illusion.  . . .’ 

The  dream  may  be  considered  as  the  hallucination  of  the  sleeping 
person,  or,  if  so  preferred,  of  what  Tissie  calls  the  splanchnic  ego.  It 
may  therefore  continue  until  the  awakening,  when  the  conscious- 
ness, being  rearoused,  should  assume  its  natural  dominion  over  the 
splanchnic  ego.  In  this  case  the  consciousness  feels  the  action  of  the 
dream  like  a psychic  wound  (De  Sanctis),  and  accepts  the  content 
of  the  dream  as  an  external  stimulus,  real  and  active,  with  all  the 
conditions  of  an  objective  sensation — with  its  emotions,  its  attrac- 
tions, its  repulsions,  and  its  dynamo-genesis.  The  emotion  produced 
by  the  dream  exercises  a strong  influence  in  these  cases,  as  Fere 
and  Toulouse  have  rightly  pointed  out. 

With  drowsiness  of  the  consciousness  and  attention,  the  activity 
of  the  sensory  areas  of  the  cerebral  cortex  is  exaggerated,  and  on 
this  fact  depends  the  reawakening  of  images  previously  stored  up 
and  associated  with  one  another,  or  new  and  momentary  formations 
arising  spontaneously  or  provoked  by  stimuli  which  naturally 
remain  outside  the  threshold  of  consciousness,  but  exercise  an 
efficient  action  on  the  sensory  centres.  Thus  it  was  that  the  iron 
of  the  bed  supporting  the  neck  of  Moury  while  asleep,  provoked 
in  him  the  dream  that  he  was  being  guillotined.  Max  Simon 
mentions  the  case  of  a geographer  who  was  studying  a chart  of  the 
lakes  of  the  interior  of  Africa,  and  who,  on  falling  asleep,  dreamt 
that  an  immense  geographical  chart  lay  open  in  front  of  him,  with 
currents  of  bluish  waters.  He  was  perspiring  ; the  coverlets  were 
the  geographical  chart,  and  rivulets  of  perspiration  were  the  currents 
of  water.  Thus  also,  one  understands  how,  when  the  stomach  is 
full,  one  may  dream  that  a hostile  hand  is  compressing  the  chest. 
Hypnotism  also  affords  a proof  of  this.  In  hypnotic  states  the 
directive  influence  of  the  will  ceases,  and  the  ordinary  conscious 
activity  is  gradually  reduced  and  confused.  For  this  reason, 
as  by  a law  of  compensation  in  the  distribution  of  the  nervous 
energy  among  the  different  areas  of  the  brain,  the  sensory 
function  is  excited  to  a much  higher  degree  by  slight  peripheral 
stimuli. 

In  these  cases  we  have,  as  a rule,  to  deal  not  with  monotonous 
hallucinations  that  surprise  the  consciousness  with  their  forcible 
insurrection,  but  rather  with  hallucinatory  scenes  acted  and 


214 


PSYCHIATRY 


sometimes  coherent,  true  reminiscences  sometimes,  in  which 
a connected  series  of  images  comes  into  play,  as  when  the 
individual  abandons  himself  rashly  to  the  suggestion  of  his 
favourite  desire. 

Some  subjects,  badly  endowed,  predisposed  to  mental  affections, 
presenting  a very  unstable  cerebral  constitution,  with  a conscious- 
ness that  is  easily  disturbed,  are  orientated  towards  a new  mental 
content  by  the  hallucinations  occurring  in  a dream,  so  that  the 
sensory  effect  remains  even  after  awakening.  In  this  case  also,  the 
consciousness  is  surprised,  and  in  a short  time  is  altered  by  the 
new  content  which  is  quickly  assimilated,  inducing  therein  a new 
order  of  ideas  and  a new  orientation  in  its  intrinsic  constitution  and 
its  relations  with  the  environment.  If  such  dreams  are  repeated 
in  the  same  manner  on  successive  nights,  as  frequently  happens, 
an  organized  delirium  becomes  set  up,  and  is  consecutive  to  these 
hallucinations.  These  are  the  so-called  hypnagogic  or  oneiric  halluci- 
nations described  by  Regis.  Sometimes  they  are  unilateral,  and  they 
are  more  frequently  so  than  is  held  by  most  people.  In  Italy, 
Seppilli  has  called  the  attention  of  clinicians  to  this  fact.  They  are 
principally  visual  hallucinations  (in  the  right  or  left  visual  fields), 
or  auditory  hallucinations  ; sometimes  they  are  tactile.  I have 
observed  several  cases  of  this  nature.  One  patient,  five  minutes 
before  a severe  epileptic  accession,  had  the  hallucination  of  the 
grotesque  figure  of  a black  man,  of  a demon,  as  he  said,  at  his  right 
side,  and  it  persisted  until  he  lost  consciousness  and  fell.  The  side 
that  was  first  affected  by  the  convulsion  was  precisely  the  right. 
In  another  case,  a young  man  who  presented  the  signs  and  symptoms 
of  a cerebral  neoplasm,  with  left  hemianopsia,  was  surprised  by 
visual  hallucinations  in  the  field  of  the  hemianopsia. 

In  asylums  it  is  not  uncommon  to  come  upon  a subject  of 
hallucination  who,  in  conversing  with  his  interlocutor,  turns  his 
head  always  to  one  side.  He  hears  the  voices,  and  sometimes  sees 
the  persons  who  are  addressing  him  on  that  side.  Regis  is  of 
opinion  that  unilateral  hallucinations  are  an  effect  of  irritation  of 
the  peripheral  organ.  Toulouse  is  more  cautious,  and  does  not 
exclude  the  central  origin  of  them.  He  seems  to  be  right,  too,  when 
we  consider  the  fact  that  in  some  cases,  as  that  to  which  I have 
referred,  the  hallucinatory  images  are  projected  upon  the  field  of 
hemianopsia. 

Let  us  now  inquire  into  the  mechanism  to  which  the  hallucina- 
tions owe  their  origin.  This  question  may  be  regarded  from  two 
different  standpoints  that  of  the  anatomical  substratum  and 
that  of  the  dynamism.  I shall  discuss  briefly  the  various  doctrines 
held  legarding  the  former.  With  these,  the  names  of  not  a few 
authors  are  associated.  Some  have  maintained  that  the  hallucina- 
tions arise  from  stimulations  of  the  peripheral  elements  of  the 
specific  nerve  in  the  case  of  visual  hallucination,  the  retina  or 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


215 


more  particularly  the  rods  and  cones  ; in  the  case  of  the  auditory, 
the  expansion  of  the  fibres  of  the  acoustic  nerve,  etc.,  in  the  internal 
ear  (cochlea,  organ  of  Corti).  This  doctrine  I hold  to  be  true 
within  certain  limits,  for  this  reason,  that  those  same  physiological 
molecular  modifications  which  we  must  recognise  in  the  peripheral 
receptive  elements,  when  these  are  subjected  to  the  action  of  physio- 
logical stimuli,  can  likewise  be  provoked  when  the  peripheral  nerve 
expansions  are  exposed  to  the  actions  of  abnormal  stimuli,  thus 
rendering  possible  the  reproduction,  in  these  elements,  of  analogous 
nerve  waves,  which,  arriving  at  the  respective  centres,  may  there 
provoke  those  same  changes  that  first  gave  origin  to  the  image. 
I have  observed  a gentleman,  well  known  in  high  commercial  circles, 
who,  after  a haemorrhage  into  the  retina,  became  the  subject  of 
visual  hallucinations  (persons,  animals),  of  which  he  always  took 
exact  account,  and  which  gradually  disappeared  in  proportion  as 
the  extravasated  blood  became  absorbed.  In  general,  however,  the 
artificial  irritations  of  the  peripheral  nervous  expansions  reproduce 
not  exactly  the  concrete  images  of  objects,  persons,  and  places,  but 
elementary  phenomena  of  the  same  sensation.  If  we  press  the 
ocular  bulb  in  the  dark,  or  stimulate  the  optic  nerve  with  electricity, 
we  see  flashes  of  light,  circles,  discs,  and  similar  phenomena  (phos- 
phenes).  Excitations  of  the  acoustic  nerve  provoke  tinklings, 
whistlings,  and  noises,  as  when  the  acoustic  nerve  is  stimulated 
with  the  electric  current. 

Nevertheless,  if  the  abnormal  stimulation  is  prolonged  or  fre- 
quently repeated  it  may,  by  means  of  the  ordinary  paths, 
augment  the  dynamic  potential  in  the  respective  cortical  zone, 
in  which  case  it  will  give  rise  to  hallucination.  I believe  that 
abnormal  stimulation,  not  only  of  the  peripheral  expansions  of 
the  specific  nerves,  but  also  of  their  trunks,  gives  rise  to  the  same 
effects. 

No  other  explanation  can  be  given  of  the  visual  hallucinations 
of  those  who  have  been  blind  for  a long  time  as  the  result  of  grave 
affections  or  enucleation  of  the  ocular  bulb.  The  same  thing  may 
be  said  of  the  hallucinations  of  individuals  who  are  deaf  through 
affections  of  the  internal  ear.  By  hallucinations  of  peripheral 
origin,  then,  we  can  understand  only  those  provoked  in  the  respective 
sensory  centres  by  abnormal  and  prolonged  stimulations  of  the 
peripheral  nervous  apparatus.  In  all  these  cases  there  is  dis- 
coverable a vesanic  constitution  of  the  patients. 

I consider  there  is  no  anatomo-pathological  or  experimental 
proof  in  support  of  the  doctrine  according  to  which  the  optic  thala- 
mus would  be  the  seat  of  the  hallucinations.  This  doctrine,  which 
is  most  strongly  advocated  by  Buys,  may  be  placed  alongside  the 
preceding,  as  we  shall  see  a little  further  on. 

From  what  we  have  written  in  the  first  part  of  this  work  and 
in  the  first  pages  of  this  chapter,  one  can  easily  deduce,  without 


2i6 


PSYCHIATRY 


entering  farther  into  details,  that  the  peripheral,  like  the  sub- 
cortical stimulations,  do  not  produce  hallucinations,  except  in  so 
far  as  they  augment  the  potential  of  the  perceptive  areas  which  are 
the  seat  of  formation  and  preservation  of  the  images. 

We  must  now  take  up  the  question  whether  the  hallucinations 
arise  by  a primary  abnormal  excitation  of  the  sensory  areas  of  the 
cerebral  cortex,  or  whether  they  are  of  intellectual  or  ideative 
origin.  The  present-day  notion  of  the  sensory  areas,  and  the  signifi- 
cance attributed  to  them  of  centres  formative  and  preservative 
of  the  images,  force  us  to  admit  that  the  hallucinations  can  only 
have  their  origin  in  the  sensory  zone.  In  this  matter  I support  the 
hypothesis  of  Tamburini,  who  has  been  the  first  to  utilize  the 
existing  knowledge  of  the  cortical  sensory  centres,  so  as  to  assign  a 
more  stable  physiological  doctrine  to  our  ideas  of  the  hallucinations. 
Hallucinations  are  phenomena  whose  organic  substratum  is  in 
every  case  the  respective  sensory  area  of  the  cortex.  The  more  or 
less  evident  alterations  that  we  find,  then,  when  we  have  the  oppor- 
tunity of  making  sections  of  the  brain  of  a subject  of  hallucination, 
are  an  irrefutable  proof  of  the  truth  of  this  doctrine.  I could 
report  many  cases  in  support  of  it,  but  deem  it  sufficient  to  give 
one  that  has  been  the  object  of  observation  quite  recently. 


Observation  2. — Bal.  P.,  fifty-five  years  of  age,  was  admitted  to 
the  wards  on  January  27,  1901. 

Twelve  years  ago  he  contracted  syphilis.  He  has  undergone 
long  and  assiduous  treatment,  and  remained  well  until  a year  and 
a half  before  admission.  In  the  summer  of  1899  a small  tumour 
made  its  appearance  in  the  upper  part  of  the  right  parietal  region, 
and  when  incised  a caseous  substance  came  from  it.  It  must  have 
been  of  gummatous  formation.  A few  months  afterwards,  clonic 
contractions  commenced  in  the  right  upper  limb,  and,  to  a less  extent, 
in  the  upper  muscular  region  of  the  facial  nerve  of  the  same  side. 
These  convulsions  have  been  repeated  at  longer  or  shorter  intervals 
in  identical  m.anner.  Lately,  the  convulsive  attack  has  been  accom- 
panied by  visual  sensory  disorders  with  ideas  of  persecution  and 
intense  motor  agitation.  On  this  account  he  has  been  brought  to 
the  asylum. 

The  objective  examination  has  given  the  following  results  : 
Tactile  sensibility  is  normal  on  the  right  side,  but  markedly  altered 
on  the  entire  left  half  of  the  body.  The  patient  does  not  always 
notice  small  contacts  made  on  the  left  side,  and  even  when  he  does, 
does  not  localize  them  with  the  same  precision  with  which  he 
localizes  them  on  the  right  side,  although  employing  always  the  right 
hand  to  indicate  the  points  touched  on  one  or  other  part  of  the 
body.  On  examination  with  the  aesthesiometer  the  difference 
between  the  two  sides  becomes  more  evident.  These  disturbances 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


217 


of  the  tactile  sensibility  increase  from  the  root  to  the  extremity 
of  the  limbs,  where  they  are  most  marked. 

The  patient  does  not  notice  the  slight  differences  of  temperature 
of  different  bodies  applied  to  the  surface  of  his  body  on  the  left 
side. 

The  sensibility  to  pain  is  slightly  diminished  towards  the 
extremity  of  the  left  upper  limb.  Muscular  sensibility  is  markedly 
altered  on  the  left  side.  The  stereognostic  sensibility  is  abolished 
on  the  left  side.  The  patient  does  not  succeed  in  defining  an  object 
placed  in  his  left  hand,  no  matter  how  much  he  handles  it.  With 
the  right  hand,  on  the  contrary,  he  perceives  and  distinguishes  even 
the  smallest  objects. 

With  each  nostril  he  distinguishes  different  odours  well. 

The  visual  strength  is  almost  normal ; the  chromatic  sense  is 
normal.  The  visual  field  is  not  hemiopic,  but  is  diminished  in  the 
two  left  halves. 

The  auditory  sensibility  is  preserved.  The  patient  frequently 
notices  strange  noises  in  his  ears — sometimes  it  is  the  booming  of 
his  own  voice  in  the  organ  of  hearing ; at  other  times  it  is  whistlings, 
hissings,  or  sounds  of  falling  rain. 

The  patient  presents  a profound  change  of  the  kinaesthetic 
sense.  He  is  continually  requesting  to  be  visited  by  the  doctor, 
because  it  seems  to  him  that  his  respiration  does  not  go  on  regu- 
larly, that  his  heart  is  affected,  and  he  suffers  from  anxiety  and 
malaise. 

The  patient  feels  cold  more  than  he  ought,  and  piles  on  as  many 
bedclothes  as  he  can  have. 

All  the  cutaneous  reflexes  are  abolished,  with  the  exception  of 
the  abdominal  reflex,  which,  however,  is  hardly  perceptible. 

The  conjunctival  reflex  is  weak  on  both  sides,  that  of  the  auditory 
canal  is  absent,  that  of  the  Schneiderian  membrane  is  preserved, 
as  are  also  the  rectal,  the  vesical,  and  the  iridean. 

The  patellar  reflexes  are  unequal,  the  left  being  more  accentu- 
ated (examination  was  made  immediately  after  a convulsive  attack). 
On  repeating  the  examination  after  the  lapse  of  a few  days,  no 
marked  difference  could  be  made  out  between  the  two  sides.  The 
reflex  of  the  tendon  Achilles  is  present,  and  the  tendon  reflexes  of 
all  the  muscles  of  the  upper  limb  can  be  provoked. 

The  permanent  psychic  disorders  of  the  patient  consist  in  a 
weakness  of  the  mental  functions,  not  very  pronounced,  especially 
of  the  power  of  attention,  for  which  reason  the  patient  is  unable  to 
undergo  a long  interrogation  or  a minute  somatic  examination 
that  requests  his  attentive  co-operation  without  being  tired.  The 
perceptive  process  is  almost  normal,  and  memory  is  normal,  as  is 
also  ideation,  delirium  being  absent. 

The  transitory  psychic  disorders  which  recur  periodically  along 
with  the  Jacksonian  accession  are  more  important.  While  imme- 


2i8 


PSYCHIATRY 


diately  before  the  accession  the  patient  notices  formication  and  a 
sense  of  heat  or  cold  in  the  left  upper  limb,  during  and  after  the 
accession  he  has  vivid  visual  hallucinations  and  illusions.  These 
have  this  characteristic,  that  the  patient  sees  strange  physiognomies, 
and  men  disguised  and  gesticulating  in  a scofhng  manner  at  his 
expense,  not  in  every  direction  of  the  room  he  occupies,  but  only 
on  his  left  side.  Frequently,  after  the  accession,  the  reaction  of  the 
patient  to  these  abnormal  sensory  products  is  rather  lively.  Lately 
he  is  convinced  that  these  disturbances  accompany  the  convulsive 
accession,  and  does  not  concern  himself  about  them  ; but  at  first 
his  consciousness  was  perturbed  by  them,  and  he  believed  himself 
the  victim  of  persecution  and  insults. 

Preoccupied  with  himself  and  his  health,  in  an  apparent  and 
superficial  expansiveness,  he  is  egoistic  and  perfectly  indifferent 
to  all  that  lies  without  the  sphere  of  his  immediate  wants.  He  is 
always  asking  something  to  eat,  and  two  rations  of  food  are  scarcely 
sufficient  to  satisfy  him.  His  stomach  being  filled,  and  having 
consulted  the  doctor  three  or  four  times  concerning  his  present 
misfortunes,  he  does  not  preoccupy  himself  with  an3dhing  else. 
He  wishes  to  be  assured  that  his  death  is  not  near  ; he  has  some 
interest  in  living  wherever  he  may  be,  within  or  without  the  as^dum. 
He  says  he  wishes  to  be  discharged,  but  he  does  not  really  desire 
it.  His  family  has  no  attraction  for  him.  His  wife  has  lived 
separate  from  him  for  some  time  ; his  sexual  function  is  almost 
dormant,  and  accordingly  he  has  nothing  to  request  from  the 
world  without. 

In  the  asylum  he  is  very  correct. 

On  January  30,  1901,  he  seemed  to  see  the  faces  of  the  mem- 
bers of  his  family  disguised,  and  deriding  him  ; then  he  saw  dead 
bodies  round  him,  masks,  wounded  persons,  men  in  threatening 
attitudes,  etc.,  and  he  heard  hissings,  noises,  and  tinklings. 

On  April  18,  1901,  he  had  renewed  attacks  of  the  Jacksonian 
type,  which  commenced  in  the  muscular  territory  of  the  left  facial 
nerve,  and  extended  to  the  limbs  of  the  same  side.  The  visual 
hallucinations  were  repeated. 

The  diagnosis  was  made  of  meningo-cerebral  gumma,  and  the 
patient  was  put  under  a rigorous  and  extensive  mercurial  treat- 
ment. 

Notwithstanding,  the  attacks  were  repeated  with  great  intensity 
on  April  18  and  21.  Purulent  bronchitis  developed.  Further 
accessions  occurred  on  the  23rd  ; death. 

The  conditions  found  at  the  autopsy  were  as  follows  : On  the 
inner  table  of  the  cranial  vault,  at  a point  corresponding  to  the 
right  parietal  eminence,  were  two  areas  of  gummatous  ostitis  and 
other  small  ones  in  the  neighbourhood.  The  cranial  bones  were  very 
thin  and  transparent  on  the  left  side,  but  thicker  on  the  right  side. 
The  dura  mater  on  the  right  side  was  greatly  thickened,  hardened 


219 


PHYSIO-PATHOLOGY  OF  PERCEPTION 

and  adherent  to  the  underlying  layers  ; at  the  points  where  it  was 
incised  it  was  seen  to  be  occupied  by  hard,  yellowish  gummatous 
nodules  and  placques.  The  lesion  extended  from  the  foot  of  the 
frontal  convolutions  to  the  occipital  lobe,  occupying  principally  the 
parietal  lobe,  from  which  a bridge  was  thrown  to  the  first  temiporal 
convolution  (Fig.  6o).  The  other  half  of  the  dura  mater  was  per- 
fectly free  ; the  left  hemisphere  showed  no  specific  alteration  of 
the  cerebral  arteries.  The  spinal  medulla  presented  no  appreciable 
alterations. 

Such  a finding  explains  all  the  symptoms  ; the  nodules  on  the 
Rolandic  zone  were  the  cause  of  the  Jacksonian  attacks  , the 
diffusion  over  all  the  somaesthetic  zone  gives  the  reason  of  the 
profound  disturbances  of  kinaesthesis  and  of  the  hypochondriacal 
condition  ; the  diffusion  backwards  on  the  occipital  lobe  and  the 


Fig.  6o. 


projection  upon  the  first  temporal  convolution  are  to  be  regarded 
as  the  immediate  cause  of  the  auditory  and  visual  hallucinations. 

Whether  hallucination  may  also  be  of  intellectual  origin — that 
is,  secondary  to  ideas  which,  by  having  reached  a high  degree  of 
intensity,  may  excite  more  strongly  than  normal  the  sensory  areas 
with  which  they  correspond,  through  the  same  associative  paths 
by  means  of  which,  in  the  formative  process,  the  sensory  phenomena 
are  primarily  associated  with  the  ideas — is  more  difficult  to  decide. 
Such  a hypothesis,  however,  is  supported  by  clinical  experience. 

The  correspondence  between  hallucination  and  delirium  is  as 
undeniable  as  between  perception  and  thought. 

The  influence  of  these  two  psychic  factors  upon  one  another  is 
reciprocal.  A phenomenon  observed  excites  the  creative  capacity 
of  thought,  just  as  the  latter  finds  confirmation  in  the  sensory  proof 
of  the  facts.  This  law  is  observed  fundamentally  in  pathology.  In 
numerous  cases  the  first  phenomenon  with  which  a delirium  mani- 
fests itself  is  a hallucination,  let  us  say  auditory,  a voice,  which  is 


220 


PSYCHIA  TRY 


then  followed  by  words  that  are  quite  distinct  and  phrases  containing 
insults,  threats,  and  so  on,  which  the  patients  sometimes  recognise 
at  first  as  a new  production  of  their  brain,  for  which  they  go  to 
doctors  for  advice,  and  later  on,  if  the  disturbance  persists,  they 
interpret  the  hallucinatory  content  by  forming  false  judgments — 
logical  deliria  with  respect  to  the  ideative  and  emotional  content  of 
the  hallucinations.  Such  deliria  are  consecutive  to  the  hallucina- 
tion. As  we  shall  see  in  another  part  of  this  work,  the  hallu- 
cinations in  such  cases  are  persistent,  and  have  a uniform  content, 
which  is  necessary,  in  the  majority  of  cases,  to  induce  a false  direction 
of  ideation  on  a prepared  emotional  basis — a new  order  of  ideas, 
which,  if  not  accepted  at  the  beginning  without  some  reserve,  later 
on  transforms  the  primary  psychic  personality  by  becoming  an 
organized  delirium.  In  other  instances,  individuals  are  certainly 
found  with  an  order  of  false  ideas  not  corresponding  with  reality,  yet, 
notwithstanding,  they  live  an  intellectual  life  of  a certain  form  of 
paradoxical  monoideism,  with  groups  of  correlative  ideas  to  which 
they  conform  their  conduct — ideas  which,  arising  primarily  from 
an  altered  formative  process  of  thought,  gain  possession  of  and  then 
transform  the  field  of  the  consciousness,  persist  there  obstinately, 
become  hypernourished,  and  hinder  any  other  group  of  ideas  from 
affirming  itself.  There  is  no  contrast,  no  corrective  to  them.  The 
monoideism  is  accentuated  by  the  individual  potential  which  over- 
flows into  the  sensory  zones  by  the  same  paths  of  communication  and 
by  the  same  selective  tendency  of  thought  to  attain  the  sensory 
proof.  In  this  case  the  potential  is  already  augmented  in  the  sensory 
spheres  (hallucinatory  latency).  It  is  evident  that  the  groups  of 
ideas  of  high  tension  awaken,  by  consonance  in  the  sensory  zone, 
images  that  are  in  strict  relation  with  them,  and  furnish  the  proof 
of  the  conception  primarily  formed.  Two  conditions  are  necessary  : 
the  increase  of  the  intellectual  potential — and  one  can  admit  that 
in  any  case  where  monoideism  prevails  in  a mind  not  disorganized — 
and  the  increase  of  the  potential  in  the  sensory  zones,  which  is 
determined  by  the  intellectual  and  emotional  potential. 

The  scheme  shown  in  Fig.  6i  gives  an  explanation  of  the  above- 
mentioned  facts,  and  harmonizes  the  various  doctrines  dealing 
with  the  genesis  of  hallucinations.  The  sensory  zone  s is  shown 
in  relation,  on  the  one  hand,  with  s',  which  represents  the  peri- 
pheral expansions  of  the  specific  nerves  or  receptive  organs,  and 
on  the  other  with  i,  which  represents  the  field  of  intelligence.  The 
potential  in  s may  be  increased  by  a prolonged,  intense,  and 
abnormal  stimulus  either  in  s or  all  along  the  course  of  the  centripetal 
paths  s'  s,  including  intermediate  stations  (optic  thalamus,  corpora 
quadrigemina,  etc.),  or  by  increase  of  the  potential  in  i,  which  over- 
flows into  s by  the  paths  i s.  It  is  always  s that  gives  rise  to  the 
hallucinations  with  its  own  material,  but  through  excitations  that 
come  to  it  from  other  parts. 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


221 


As  is  apparent,  the  sensory  centre  must  remain  intact,  so  as  to 
give  rise  to  the  hallucination,  and  in  this  matter  I agree  entirely 
with  Tamburini  and  Joffroy.  At  the  most,  it  may  be  the  seat  of 
an  alteration  compatible  with  its  activity,  which,  as  regards  both 
the  raw  material  that  arrives  there  from  the  periphery  and  that 
which  comes  from  the  intellectual  field,  does  not  display  itself  more 
often  in  hallucinatory  productions  than  in  natures  with  a vesanic 
predisposition. 

The  visual  hallucinations  that  sometimes  occur  in  the  field  of 
hemiopia  do  not  contradict  this  conclusion,  because  in  such  cases 
hemianopsia  is  produced  by  a subcortical  lesion,  the  centre  remaining 
intact,  as  in  one  of  the  preceding  observations,  or  by  a partial 
lesion  of  the  cortical  centre.  In  this  connection  the  observations 
of  Fere,  Bidon,  Higier,  Colman,  Lamy,  and  some  others  are  very 
instructive. 

Such  an  induction  is  supported  by  the  fact  that  abnormal 
stimulation  of  a single  retina  produces  bilateral  hallucinations. 


This  need  cause  no  surprise  when  we  remember  the  perfect  corre- 
spondence between  the  sensory  centres  of  the  two  hemispheres 
(this  explains  the  comparative  rarity  of  unilateral  hallucinations), 
and  the  results  of  the  experimental  researches  of  Fechner,  Wundt, 
Helmholtz,  Bedard,  Ebbinghaus,  and  Titchener,  who  proved  that 
excitation  of  one  eye  produces  consecutive  images  in  the  other, 
which  can  only  happen  through  the  intervention  of  the  cortical  areas. 

The  other  aspect  under  which  the  problem  of  hallucination  is 
considered  is  that  of  the  dynamism.  The  potential  which  increases 
in  the  sensory  zone,  which  prepares  and  gives  rise  to  the  hallucina- 
tions, the  instantaneous  and  forcible  rising  of  these,  the  dominant  in- 
fluence they  exert  upon  the  consciousness  (which  has  led  J ames  to  say 
that  hallucinations  are  a strictly  sensational  form  of  consciousness), 
should  suggest  to  our  minds  an  impediment  to  the  discharge  of  the 
dynamic  tensions  in  the  nerve-elements  of  the  sensory  zones.  When 
the  sensory  zones  are  in  free  communication  with  one  another,  the 
nerve-waves,  no  matter  how  and  in  whatever  number  they  may 


222 


PSYCHIATRY 


reach  them  from,  without,  are  continually  transmitted  and  dispersed 
to  other  near  or  distant  nerve-elements,  and  determine  that  con- 
stant change  of  psychic  motion  which  is  the  most  characteristic 
phenomenon  of  norm.al  life.  This  happens  when  all  the  anatomical 
components  of  the  cortex  are  in  a condition  to  receive  and  trans- 
form, and  in  their  turn  to  transmit,  by  their  inherent  virtue,  the 
existing  nerve-waves.  The  continual  alternation  of  vibratory 
states  and  of  states  of  repose  of  myriads  of  cell-groups,  under  infinite 
internal  and  external  stimuli,  is  the  condition  of  equilibrium  in  which 
we  can  sum.  up  all  the  infinite  attitudes  of  thought  in  the  wide  field 
of  the  mind.  If  the  tensions  produced  by  a high  potential  do  not 
find  the  communications  open,  and  are  therefore  unable  to  discharge 
themselves  upon  other  nerve-elements  and  be  transformed  into 
other  psychic  products,  they  discharge  themselves  by  those  paths 
where  they  meet  the  least  resistance,  with  all  the  characters  of  a 
sensory  convulsion  (epileptic)  ; and  the  discharge  is  of  such  a nature 
that  it  produces,  on  the  one  hand,  an  exhaustion  of  the  highest 
psychic  powers,  especially  when  these  are  not  strongly  organized, 
and  on  the  other,  a new  orientation  of  the  consciousness,  surprised 
by  the  unusual  phenom.enon  and  conquered  by  the  new  invader. 
In  strongly  organized  minds  the  hallucinatory  surprise  of  the  con- 
sciousness is  soon  corrected  by  the  regulative  powers,  which  resist 
the  disintegrating  and  destructive  violence  of  the  hallucination.  This 
occurs  in  the  case  of  the  periodic  hallucinations  of  men  who  perhaps 
are  fatigued  but  are  of  sound  m.ental  constitution.  Even  in  these 
cases  the  ideative  constriction  is  produced  by  a conscious  or  sub- 
conscious em.otional  state,  which  interrupts  all,  or  almost  all,  the 
communications  with  the  entire  intellectual  field,  and  exercises 
a coercive  influence  on  the  consciousness  with  regard  to  the 
hallucinatory  emotional  images,  which,  by  their  vividness  and 
their  intrinsic  character,  would  strongly  augment  the  potential  in 
the  respective  sensory  nervous  components. 

What  takes  place  in  individuals  who  are  predisposed  and  of  a 
vesanic  constitution  is  quite  different. 

The  vesanic  constitution,  so  far  as  hallucinations  are  concerned, 
is  characterized  by  : 

1.  The  prom.pt  closing  of  the  paths  of  outlet  of  the  nervous 
tensions,  and  the  m.ore  or  less  complete  isolation  of  the  emotional 
consciousness. 

2.  The  prompt  increase  of  the  sensory  potential  and  the  tendency 
towards  stability  of  the  same. 

3.  The  prompt  captivation  and  spoliation  of  the  high  regulative 
powers 

In  these  psychopathic  natures,  the  delirious  idea  flourishes  in 
an  emotional  and  favourable  soil,  and  soon  arouses  the  analogous 
hallucinations.  It  is  quite  different  in  cases  of  mental  concentra- 
tion, em.otional  or  othenvise,  occurring  in  sane  persons  confronted 


PHYSIO-PATHOLOGY  OF  PERCEPTION 


223 


by  the  most  diverse  difficulties  of  life,  or  in  the  investigator  who 
sometim,es  assumes  the  characteristics  of  true  scientific  monoideism. 
In  neither  case  do  we  get  hallucinations.  I have  known  some 
men  to  have  been  engaged  for  months  at  a thesis,  to  have 
concentrated  all  their  mental  energies  upon  it,  to  have  given  to  it 
their  whole  activity,  and  to  have  spent  very  many  hours  upon  it 
both  day  and  night,  abstaining  from  many  ordinary  interests  and 
recreations,  and  yet  no  sensory  disorder  has  shown  itself  in  these 
cases.  The  explanation  of  this  lies  in  the  fact  that,  under  ordinary 
circumstances,  the  emotional  states  of  well-organized  men  are  pro- 
portionate to  the  cause  and  not  very  persistent  ; and  the  scientific 
theme  of  the  true  observer  and  thinker  always  disposes  of  a vast 
mental  dominion,  through  which  nerve  tensions  are  discharged  in 
the  most  diverse  directions  ; while  the  incentive  of  the  hallucina- 
tion is  alwa}3  of  an  inferior  nature  (sensory-emotional),  and  therefore 
less  capable,  notwithstanding  the  high  potential,  of  assuming 
numerous  relations  in  the  constricted  intellectual  field. 

The  content  and  form  of  the  hallucination  sometimes  possess  a 
diagnostic  significance.  Auditory  hallucinations  are  most  fre- 
quently met  with  in  paranoics,  persecuted  and  persecutors  ; the 
visual  are  most  frequent  in  religious  paranoics,  in  the  subjects  of 
hysteria,  and  in  alcoholists  ; the  tactile  are  most  common  in  acute 
forms  of  sensory  delirium  of  toxic  or  infective  origin  ; the  olfactory 
are  most  frequently  found  in  onanists  (paranoics  and  dements) 
and  epileptics.  In  epilepsy  they  are  more  elementary,  taking  the 
form  of  flames,  blood,  noises,  gunshots,  in  the  midst  of  mournful 
scenes  of  carnage,  and  of  threatening  enemies  and  aggressors  ; in 
hysteria  they  are  most  frequently  of  erotico-mystic  content,  and 
of  animals.  Sometimes  they  are  also  terrifying  and  stereotypic, 
but  solitary,  being  repeated  always  in  identical  form  in  a vivid 
manner,  or  they  are  pseudo-hallucinations  which  sometimes  de- 
termine cataleptic  states  and  violent  convulsions.  It  is  impossible 
to  enter  further  into  details  on  this  subject  until  we  discuss  the 
individual  psychopathies  in  the  third  part  of  the  work. 


CHAPTER  II 


PHYSIO-PATHOLOGY  OF  ATTENTION 


Attention  is  a psychic  fact  interposed  between  perception,  or  its 
ideative  equivalent,  and  the  reaction  which  that  tends  to  provoke. 
Attention,  therefore,  ranks  amongst  the  highest  reflex  processes, 
such  as  conscious  and  voluntary  movements  and  their  inhibition. 
It  is  not  the  will,  as  some  have  believed,  nor  is  it  apperception.  It 
contributes  to  the  process  of  apperception,  and  to  the  direction  of 
the  will  in  the  mechanism  of  conscious  reaction.  In  general  terms, 
it  may  be  considered  as  a reflex  process,  because,  to  determine 
attention,  there  are  required  a stimulus,  or  its  ideative  equivalent, 
and  the  motor  phenomena  to  which  it  gives  rise  even  when  it  inhibits. 
It  is  a phenomenon  occurring  only  in  the  conscious  state,  and  is 
evolved  and  works  in  the  field  of  consciousness. 

I am  unable  to  agree  with  those  who,  like  Roux,  hold  that 
attention  can  exist  outside  the  realm  of  consciousness,  and  lik^ 
James  Mill,  that  the  process  of  attention  is  essentially  passive 
the  active  elements  being  simply  an  added  fact — the  will, 
the  essential  moment  in  apperception,  and  as  the  author  of  til 
faculty  of  mental  synthesis  (Janet),  it  cannot  be  otherwise  thai 
conscious  in  its  highest  and  most  efficacious  manifestations. 

When  an  individual  turns  his  sensory  organs  upon  an  objecj 
that  has  stimulated  them,  to  gain  a perception  of  that  object,  then 
is  a sensory  adaptation,  voluntary  or  involuntary  ; but  if  then 
is  perception,  of  whatever  degree,  he  performs  a conscious  act.] 
Attention  is  therefore  a phenomenon  in  consciousness,  and  active,' 
as  Sully  says,  just  as  a conscious  movement  is  active,  and  therefore 
we  must  recognise  in  it  the  most  diverse  gradations,  from  that  which 
borders  upon  the  reflex  process  to  that  which  is  the  expression  of 
the  strongest  will.  Its  purpose  in  general  is  to  detain  in  conscious- 
ness the  image  of  the  object  that  has  awakened  the  activity  of  the 
senses,  an  idea  or  a group  of  ideas,  or  an  emotional  state  of  mind 
with  its  relative  ideas. 

Thus  attention  appears  to  be  the  power  of  detention  in  con- 
ciousness  (Sully,  Ribot).  This  power  is  more  or  less  strong  accord- 


PHYSIO-PATHOLOGY  OF  ATTENTION 


225 


ing  as  attention  is  voluntary  or  not,  and  this  is  a necessary  con- 
sideration. A noise,  a voice,  music,  contact,  the  presence  of  a 
person  or  a light,  if  they  do  not  determine  states  of  consciousness, 
will  certainly  not  awaken  a process  of  attention,  such  a process 
coming  into  action,  with  or  without  the  consent  of  the  subject, 
only  if  those  stimuli  determine  states  of  consciousness.  In  such  a 
case,  according  to  the  nature  of  the  stimulus  and  the  interest  it 
excites,  the  image  is  detained  in  consciousness  by  the  act  of  per- 
ception or  apperception,  and  this  gives  rise  to  a particular  motor 
adaptation,  which  will  be  described  farther  on. 

Everything  that  is  voluntarily  detained  in  consciousness  by 
the  process  of  attention  is  sustained  by  a greater  or  less  number 
of  ps}7chic  components  evoked  and  associated,  and  in  this  way  the 
objective  qualities  of  present  things  are  always  better  distinguished 
and  the  groups  of  representations  completed. 

The  object  of  attention  is  not  solely  to  arrest  a psychic  fact 
in  consciousness,  a function  which  caused  Sully  to  say,  ‘ Attention 
is  detention  in  consciousness  sometimes  it  has  for  its  object  the 
removal  from  consciousness  of  groups  of  images  or  other  psychic 
components  out  of  harmony  with  the  tone  of  the  personality  at 
any  given  time,  and  the  substitution  of  others  more  in  harmony 
with  it.  As  a matter  of  fact,  everyone  has  found  himself  at  times 
unwilling  to  think  of  a certain  matter,  event,  or  product  of  his 
imagination,  and  anxious,  as  we  say,  to  drive  away  certain  thoughts. 
In  these  cases  the  elimination  is  effected  by  substitution,  our  atten- 
tion being  turned  to  other  objects  and  calling  up  other  memories, 
which  occupy  the  field  of  consciousness  in  substitution  of  the  first. 
While  we  do  not  admit  that  attention  may  exist  outside  of  con- 
sciousness, we  must  not  fail  to  divide  it  into  voluntary  and  in- 
voluntary attention,  and  we  must  reject  as  very  improbable  the 
idea  expressed  by  Hamilton  that  attention  is  nothing  more  than 
a fact  of  consciousness. 

‘ x\ttention,’  he  says,  ‘ is  consciousness  and  something  more  : 
it  is  consciousness  concentrated  ’ on  some  determined  object.  It 
is  like  the  point  of  convergence  of  two  forces  acting  in  opposite 
direction.  One  of  these  is  the  intrinsic  property  of  the  action  of 
external  agents  on  the  nervous  element,  and  of  the  adaptation  of 
this  element  to  their  demands,  its  direction  being  from  without  to 
within  ; the  other  emanates  from  the  power  of  the  ideas  or  the 
emotions  that  pass  through  the  field  of  consciousness  independent 
of  any  actual  agent,  and  most  frequently  arises  from  the  uncon- 
scious. This  second  form  of  attention  is  in  great  measure  produced 
by  education,  and  it  has  its  maximum  value  in  the  process  of  apper- 
ception. 

If  the  matter  be  well  considered  it  will  be  seen  that  these  enuncia- 
tions go  beyond  the  truth.  Attention  shows  a gradual  evolution. 
From  automatism — which,  however,  upon  lies  the  threshold  of  con- 

15 


226 


PSYCHIATRY 


sciousness — there  is  a gradual  advance  to  the  highest  confirmation 
of  the  concentrative  and  extensive  power  of  the  mind.  This  is 
often  the  product  of  education. 

The  first  object  that  education  proposes  to  itself  is  the  formation 
of  a habit  of  work,  and  voluntary  attention  is  work.  Everyone 
feels  the  effort  that  profound  and  prolonged  reflection  costs.  Our 
willingness  to  give  attention  has  caused  Bastian  to  say,  and  not 
without  reason,  that  ‘ all  the  processes  of  voluntary  attention  are 
complex  phenomena  composed  of  volition  and  attention.’  Educa- 
tion, during  the  period  of  mental  development  in  the  young,  tends 
precisely  to  substitute  voluntary  for  involuntary  or  sensory  atten- 
tion by  all  the  means  so  well  known  in  the  art  of  teaching.  The 
exercise  of  the  will  in  the  process  of  attention  creates  both  the 
habit  of  reflection  and  a reflective  attitude  of  mind,  and  so  diminishes 
the  effort  required. 

Education  must  furnish  compensations  for  the  labour  of  atten- 
tion, which  is  an  effort,  and  breaks  the  general  law  of  habit — indis^ 
tinguishable  from  the  law  of  least  resistance.  It  is  through  attention 
that  ideas,  existing  but  lost  in  the  deep  sea  of  oblivion,  are  most 
promptly  recalled  to  consciousness,  and  also  by  its  means  that  new 
ideas  are  created  by  the  enlargement  of  our  network  of  associations 
in  the  process  of  apperception.  The  enlargement  of  our  range  of 
associations  by  pausing  upon  the  object  of  attention,  or  by  an 
adequate  distribution  of  attention — thus  facilitating  the  knowledge 
of  the  greatest  number  of  objects  in  a minimum  of  time — is  the 
great  secret  of  all  progress,  which  consists  at  bottom  in  the  perfec- 
ting of  our  notion  of  things,  and  of  our  cosmic  and  historico- 
social  environment.  Many  men  of  genius  owe  the  vigour  of  their 
conceptions  to  the  penetration  and  constancy  of  their  power  of 
reflection,  and  to  the  due  distribution  of  that  power. 

Voluntary  attention  has,  further,  the  power  to  excite  and  to 
regulate  in  consciousness  the  movements  of  the  psychic  components 
of  the  personality,  either  under  the  influence  of  external  stimuli 
or  under  that  of  a more  or  less  complex  mental  derivative.  The 
effect  of  this  is  to  increase  the  intensity  of  a representation  and  to 
render  it  clearer  by  isolating  it  from  other  representations  that  do 
not  contribute  any  increase  to  its  intensity  (N.  Lange). 

Involuntary  attention  is  the  coercion  exercised  upon  the  person- 
ality by  external  stimuli  through  the  sensory  organs  respectively 
excited.  Between  this  and  voluntary  attention  there  is  a chain  of 
psychic  facts  that  range  from  instinct  to  habit,  to  conation,  to 
effort  (De  Sanctis),  inasmuch  as  instinct  and  habit  have  an  element 
of  consciousness  and  of  voluntary  conation. 

One  of  the  most  notable  effects  of  the  force  of  reflection  is  the 
augmentation  of  feeble  stimuli  to  varying  degrees  of  potentiality. 
This  augmentation  is  easily  understood  when  we  remember  the 
accommodation  of  the  consciousness  and  the  preparation  of  the 


PHYSIO-PATHOLOGY  OF  ATTENTION 


227 


imaginative  centres  for  the  reception  of  the  new  guest,  whose  impor- 
tance varies  according  to  the  number  of  its  relations,  in  conscious- 
ness, with  former  psychic  components  of  the  personality  ready  to 
come  into  touch  with  it. 

This  phenomenon  has  been  recognised  and  denoted  by  the 
word  ‘ preperception.’  It  had  already  been  well  defined  by  Helm- 
holtz and  Wundt  as  the  preparation  of  the  perceptive  field  for 
feeble  stimuli,  and  in  my  opinion  Ribot  and  Lange  are  wrong  in 
judging  it  to  be  subsequent  to  the  muscular  adjustment. 

This  convocation  in  consciousness,  or  on  its  threshold,  of  a 
richer  mental  content  ready  to  assume  associative  relations  with 
the  new  percept,  while  it  facilitates  perception,  is  the  foundation 
of  the  imagination  on  the  one  hand,  and  of  sensory  errors — illusions — 
on  the  other.  How  often  have  we  experienced  the  fleeting  illusion 
of  believing  persons,  things,  and  circumstances  to  be  present  just 
because  our  minds  were  at  the  moment  filled  with  those  determined 
ideas,  coloured  by  the  emotions  of  fear,  eager  desire,  suspicion, 
etc.,  that  give  their  stamp  to  the  new  percept  ? Here  we 
have  the  concurrence  of  all  the  mental  residua  organized  in  the 
unconscious  and  giving  each  individual  his  particular  tone,  inas- 
much as  the  cumulative  effect  of  the  past  projects  itself  into  con- 
sciousness, fixing  there  a series  of  predominating  interests. 

Certainly  the  original  disposition  and  the  receptivity  of  the 
personality  must  have  a very  great  influence  on  the  reflective  power, 
since  both  sensory  and  voluntary  attention  are  nourished  and 
reinvigorated  by  interest  in  things,  and  by  the  two  fundamental 
emotions,  pleasure  and  pain,  under  the  action  of  various  external 
agents  and  their  psychic  derivatives. 

Maudsley,  Carpenter,  Horwicz,  Ribot,  and  others,  have  already 
pointed  out  the  emotive  and  affective  origins  of  attention.  The 
two  fundamental  feelings  have  a notable  effect  in  raising  the  tone 
of  the  attention,  which  returns  by  preference  to  the  objects  of 
pleasurable  sensation,  accumulated  by  experience  and  fixed  in  the 
respective  cerebral  reticula.  As  pleasure  presents  infinite  grada- 
tions, from  the  lowest  and  purely  instinctive  to  the  highest — such 
as  intellectual,  moral,  and  aesthetic  pleasures — we  can  figure  to  our- 
selves attention  as  represented  by  so  many  concentric  curves  showing 
the  gradations  of  pleasurable  feelings,  involving  acts  of  voluntary 
selection  to  fix  in  consciousness  the  objects  harmonizing  with  those 
feelings,  and  by  another  system  of  curves,  opposed  to  the  first, 
representing  gradations  of  painful  feelings,  with  regard  to  which 
the  selective  power  is  devoted,  under  the  direction  of  attention, 
to  the  removal  from  consciousness  of  all  that  influences  the  person- 
ality in  a painful  way  and  in  opposition  to  the  fundamental 
laws  of  its  existence.  Bearing  this  in  mind,  it  becomes  clear  that 
in  the  power  of  attention  we  shall  find  one  index  of  the  will-power 
of  the  person. 


15—2 


228 


PSYCHIATRY 


From  the  fact  that  attention  cannot  be  brought  into  play 
unless  by  peculiar  muscular  accommodation,  there  has  arisen  the 
doctrine,  supported  by  many  physiologists  and  psychologists,  that 
attention  is  a motor  phenomenon.  No  one  has  any  difficulty  in 
recognising  the  general  attitude  assumed  by  an  observant  individual. 

The  gradual  arrest  of  bodily  movements  (especially  of  loco- 
motion) in  proportion  to  the  intensity  of  the  attention,  the  con- 
traction of  the  brow  and  the  superciliary  region,  the  peculiar  immo- 
bility of  the  facial  muscles,  the  fixity  of  the  regard,  and  the  dila- 
tation of  the  pupils,  are  the  expression  of  so  many  muscular  move- 
ments. As  Fechner,  Lewes,  and  Bain  were  among  the  first  to 
observe,  some  of  these  are  intrinsic  to  each  idea,  and  give  particular 
muscular  representations  proper  to  the  motor  adjustment  both 
in  sensory  and  in  intellectual  attention,  causing  some  to  consider 
the  latter  form  to  be  less  intense  and  noticeable  than  the  former. 
Others  among  these  muscular  actions  correspond  to  the  movements 
of  adaptation  and  of  arrest.  But  if  the  motor  accommodation  be 
the  confirmation  of  a general  law,  derived  in  part  from  the  presence 
of  the  motor  component  of  each  sensation,  and  therefore  of  each 
idea,  leading  in  the  process  of  attention  to  a motor  manifestation, 
which  itself  is  equivalent  to  the  sum  of  the  motor  components  of 
all  the  ideas  that  attention  brings  together  and  synthetizes,  their 
energy  being  resolved  into  a resultant  that  brings  the  greater  part 
of  the  muscles  of  the  body  into  a state  of  arrested  motion,  that  is 
very  far  from  giving  the  phenomenon  the  significance  of  the  intimate 
motor  nature  of  the  activity  displayed  in  attention.  The  most  that 
we  can  say  is  that,  in  a function  so  complex  as  attention,  the  motor 
factor  is  but  one  of  the  components,  and  not  the  whole  function ; 
nor  does  it  explain  the  process,  still  less  the  effect  of  it.  In  fact, 
if  we  fix  our  attention  upon  an  object  or  an  idea,  we  can  clearly 
distinguish  the  phenomenon  of  the  conation,  or  the  evocation  and 
concentration  in  consciousness  of  a greater  or  less  number  of  psychic 
components,  from  the  sensation  that  arises  from  the  peculiar 
muscular  activity,  which  is  often  nothing  more  than  the  effect  of 
the  inhibition  caused  by  the  extraordinary  intellectual  concentration 
in  the  field  of  consciousness.  Other  muscular  sensations  are  more 
intrinsically  connected  with  the  nature  of  the  images  evoked,  for 
example,  when  we  think,  and  at  the  same  time  speak,  internally, 
as  we  say,  this  internal  speech  associates  itself  more  or  less  in 
^’arious  men  with  a rudimentary  articulation  of  the  words ; again, 
when  we  recall  ideas  of  form,  say  the  circle,  the  sensation  of  the 
motor  adjustment  perhaps  predominates.  If,  however,  we  evoke 
and  visualize  images  of  colour,  the  motor  component  of  attention 
is  reduced  to  a very  small  matter,  generally  only  to  what  forms 
part  of  the  word  corresponding  to  the  image  evoked  and  to  the 
special  relations  of  the  latter.  It  is  certain  that  we  can  exercise  a 
very  strong  power  of  attention  when  in  a horizontal  position,  lying 


PHYSIO-PATHOLOGY  OF  ATTENTION  229 

on  the  side  or  the  back.  How  often  does  it  happen  that  we  awake 
in  the  night,  especially  when  we  have  gone  to  sleep  with  the  mind 
preoccupied,  and  reflect  intensely  on  the  subject  of  our  preoccupa- 
tion with  all  our  mental  resources  ? Though  in  these  cases  we  cannot 
deny  that  there  is  a change  in  the  muscular  tone,  yet  it  must  be 
agreed  that  the  muscular  action  is  reduced  to  an  almost  imper- 
ceptible minimum.  Certainly  there  is  no  proportion  between  the 
reflective  activity  and  the  work  of  the  muscles. 

Those  who  maintain  the  muscular  nature  of  attention  adduce  m 
support  of  their  hypothesis  the  pain  in  the  occiput  suffered  by  those 
who  reflect  long  and  intensely.  This  pain  in  the  occiput  and  the 
muscular  sensations  characteristic  of  ideative  attention  are  not  due 
to  weariness  of  the  organs  of  the  senses,  but  have  their  seat  in  the 
soft  parts  of  the  head.  Fechner  believes  that  these  depend  on  the 
contraction  of  the  muscles  of  the  skin  of  the  occiput,  and  Miinster- 
berg  that  they  are  concomitants  of  the  fixation  of  the  head  due  to 
the  muscular  adjustment  of  attention. 

If  we  recognise,  then,  with  almost  all  the  psychologists  and 
physiologists,  that  the  sensations  of  motor  adaptation  enter  as 
components  into  the  complex  fact  of  attention,  everyone  may  con- 
vince himself,  by  the  method  of  introspection,  which  Sully  appears 
to  have  preferred,  that  the  essence  of  the  psychic  fact  of  the  con- 
scious concentration  of  intellectual  and  emotional  components 
cannot  be  confused  with  the  motor  phenomena  that  accompany  it. 
In  other  words,  attention  cannot  be  conceived  as  a motor  function. 
It  is  within  the  power  of  all  to  convince  themselves  that  attentive 
visual  observation  of  an  object  is  possible  without  moving  the  eyes, 
as  when  we  fix  our  look  on  one  point  of  the  held  of  vision  and  obser\  e 
some  object  towards  the  periphery  of  that  field.  I cannot  persuade 
myself  that  the  fixation  of  the  body,  of  its  parts,  of  the  organs  of 
sense  (the  eyes),  at  the  point  of  equilibrium,  as  it  were,  of  all  the 
antagonistic  muscular  forces,  dependent  in  its  turn  on  the  inhibi- 
tion of  diffuse  movements,  is  the  substantial  fact  of  attention,  when 
I think  that  a man  who  is  utterly  paralyzed  can  direct  his  thoughts 
at  will. 

I have  had  under  my  care  a learned  professor  of  literature  and 
theology,  of  the  Order  of  Propagandists,  who,  after  a panegyric, 
had  a serious  attack  of  polyneuritis  that  spared  only  the  muscles 
innervated  by  the  cranial  nerves.  He  showed  the  most  complete 
muscular  resolution,  and  there  was  no  faradic  reaction.  In  this 
state,  for  many  months,  that  man  was  able  to  direct  his  will  per- 
fectly to  all  the  verbal  manifestations  of  his  thought.  He  had  lost 
none  of  his  strong  power  of  attention. 

From  these  observations  it  is  more  than  permissible  to  infer 
that  the  motor  fact  is  the  visible  phenomenon  by  which  attention 
is  recognised,  and  it  has  two  sources  : on  the  one  hand,  it  is  the 
movement  of  the  organs  of  sense,  of  the  head  and  the  trunk,  towards 


230 


PSYCHIATRY 


the  actual  stimulus — the  reflex  or  instinctive  attention  of  N.  Lange  ; 
on  the  other  hand,  it  is  the  increased  spinal  innervation  (tone)  of 
the  muscles,  due  to  the  concentration  of  the  cerebral  energy  on  the 
object  of  attention  (inhibition). 

We  must  not,  however,  neglect  the  motor  component  that  is  an 
integral  part  of  every  image,  for  it  is  of  no  less  importance  than  the 
state  of  inhibition  in  which  the  whole  muscular  system  is  placed  in 
consequence  of  the  conscious  concentration  of  ideas.  The  one  form 
of  movement  is  specific  and  individualized  for  each  idea  ; the  other 
is  general  and  uniform,  whatever  be  the  nature  of  the  ideas  convoked 
and  concentrated  by  attention. 

Some  psychologists  and  physiologists  have  put  forward  the 
question  of  the  cerebral  seat  of  attention.  Among  them  two  of 
the  most  strenuous  supporters  of  a seat  of  attention  are  Ferrier  and 
Wundt. 

As  I have  mentioned  in  the  first  part  of  this  work,  Ferrier 
localizes  the  ‘ faculty  of  attention  ’ in  the  frontal  lobes.  His 
hypothesis  is  logical.  When  once  he  concludes  that  ‘ the  faculty 
of  attention,  with  all  that  it  implies  in  the  sphere  of  the  intellectual 
operations,  must  be  intimately  related  to  the  volitional  control 
(muscular)  of  the  head  and  the  eyes,  in  association  with  the 
centres  of  visual  perception  and  ideation,’  and  since  the  motor 
centres  of  the  head  and  the  eyes  are  localized  in  the  frontal 
lobes,  attention  becomes  essentially  a motor  function,  in  his  view, 
and  its  seat  must  be  that  of  the  movements  of  the  head  and  the 
eyes.  I reproduce  his  actual  words,  referring  to  the  behaviour  of 
apes  deprived  of  their  frontal  lobes  : ‘ It  is  a form  of  mental  degra- 
dation that  seems  to  me  to  depend  upon  the  loss  of  the  faculty  of 
attention,  and  my  hypothesis  is  that  the  power  of  attention  is 
wholly  connected  with  the  voluntary  movements  of  the  head  and 
the  eyes.’ 

I had  to  criticise  that  hypothesis  many  }^ears  ago  (‘  On  Functions 
of  Frontal  Lobes  ’ Brain,  1895),  and  in  the  first  part  of  this  work 
the  reader  will  find  what  is,  in  my  opinion,  the  function  of  the 
frontal  lobe. 

Wundt  also  localizes  apperception — which,  according  to  him,  is 
attention — in  the  frontal  lobe.  It  will  be  useful  to  give  here  his 
idea  in  full : When  an  external  object  awakens  attention,  the  first 
effect  is  the  formation  of  an  image  of  the  intuitive  order,  but  not 
definite.  The  sensory  irritation  is  at  the  same  time  transmitted 
to  the  central  territory  of  the  apperception.  Then  the  stimulus 
follows  a twofold  direction — towards  the  sensory  territory,  with 
the  effect  of  strengthening  the  image,  and  towards  the  motor 
centres  that  innervate  the  voluntary  muscles,  whence  we  have 
that  muscular  tension  which  causes  the  feeling  of  effort  that  ac- 
companies attention,  and  in  its  turn  reacts  upon  the  attention  so  as 
to  strengthen  it. 


PHYSIO-PATHOLOGY  OF  ATTENTION 


231 


As  I have  set  forth  the  complex  function  of  the  frontal  lobe  in 
the  first  part  of  this  work,  I merely  state  now  my  conviction,  in 
which  I am  at  one  with  Bastian  and  others,  that  the  frontal  lobe  is 
the  organ  of  attention,  in  so  far  as  it  is  the  one  on  which  we  bring 
together  the  whole  intellectual  and  emotional  patrimony  of  the  per- 
sonality, and  in  so  far  as  it  is  the  centre  for  summoning  up  separate 
images,  of  which  the  equivalents  or  duplicates  are  sent  from  the 
sensory  zones  to  the  frontal  lobes  for  physiological  fusion  with  others 
and  for  the  formation  of  mental  products  of  a more  elevated 
order. 

The  attitude  of  readiness,  of  expectant  attention  (anticipated 
attention),  shortens  very  much  the  time  of  reaction— the  time  that 
elapses  from  the  moment  of  the  impression  to  the  moment  of  the 
reaction,  which  denotes  that  there  is  perception — until  the  interval 
completely  disappears.  To  give  an  example,  this  interval  falls 
from  to  of  a second,  and  sometimes  disappears ; but  dis- 
tractions increase  the  interval  enormously. 

With  these  methods  we  shall  be  able  to  find  a mode  of  obtaining 
the  measure  of  attention,  or,  in  other  words,  the  reflective  equation. 
The  methods  introduced  in  the  researches  of  Wundt  and  followed 
with  greater  or  less  modification  by  Tschisch,  Obersteiner,  Miin- 
sterberg,  Bartels,  Lange,  Baldwin,  Janet,  and  others,  and  in  Italy 
especially  by  Buccola  and  Patrizi,  have  given  only  modest  results. 
James  Swift’s  methods  deserve  more  attention  (‘  Disturbance  of  the 
Attention  during  Simple  Mental  Attention,’  Journ.  of  Psychol., 
1892).  Experimenting  under  exactly  similar  conditions.  Swift 
succeeded  in  proving  that  in  100  cases,  while  the  time  of  simple 
reaction  was  0-103  seconds,  it  was  increased  to  0-122  seconds  when 
the  attention  was  disturbed  by  a metronome  beating  120  to  the 
minute.  In  other  series  of  experiments  the  range  was  from  o-iio 
for  simple  reaction  to  0-158  for  reaction  with  disturbed  attention. 

As  we  have  seen  in  Chapter  I.,  the  time  of  simple  reaction  is 
much  shorter  than  the  time  of  reaction  where  there  is  a choice.  In 
the  choice  the  attention  plays  an  important  part,  but  the  interval 
is  very  much  extended  when  the  attention  is  disturbed.  As  a 
matter  of  fact,  the  time  of  reaction  with  choice,  which  was  0-179  in 
Swift’s  experiments,  was  increased  to  0-197  by  the  mere  intervention 
of  the  sound  of  the  metronome,  and  when  the  attention  had  turned 
to  the  cause  of  the  disturbance  it  mounted  to  0-265.  The  same 
results,  except  for  difference  in  the  figures,  were  given  by  experi- 
ments in  which  the  distracting  stimuli  were  lights,  or  were  of  a 
more  complex  nature,  such  as  the  repetition  of  a piece  of  poetry 
learned  by  heart,  reading,  etc. 

Birch  (‘A  Study  of  Certain  Methods  of  Distracting  the  Atten- 
tion,’ Amer.  Journ.  of  Psychol.,  1897-1898) .has  adopted  a method, 
which,  if  it  has  not  given  any  new  results  and  sure  conclusions, 
promises  many  positive  facts  for  the  physiopathology  of  attention. 


232 


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He  used  a number  of  odours  to  distract  the  attention,  and  he  dis- 
tributes the  results  he  got  into  four  series  : 

1.  Distraction  caused  by  familiar  odours  that  could  not  be 
named. 

2.  Distractions  due  to  odours  that  were  very  familiar  through 
the  recollections  they  awakened  ; in  this  case  attention  turns  upon 
the  recollections. 

3.  Distraction  due  to  unfamiliar  or  nauseous  odours. 

4.  Distraction  due  to  easily  recognisable  odours,  the  recognition 
of  which,  however,  suggests  ideas  extraneous  to  the  experiment. 

All  stimuli,  however,  do  not  possess  equal  power  of  distraction. 
From  the  interesting  observations  of  Darlington  and  Talbot  (Amer. 
Journ.  of  Psychol.,  1897-1898)  we  have  the  general  result  that  music 
facilitates  the  attention  in  place  of  inhibiting  it. 

The  stimulus  chosen  to  distract  sometimes  reinforces  or  facili- 
tates attention.  In  general,  the  stimuli  that  cause  the  greatest 
distraction  are  emotional  ; those  appealing  more  directly  to  the 
intellect,  while  they  demand  more  active  attention,  are  less  dis- 
tracting. 

I have  said  ‘ modest  results,’  because  we  may  agree  with  Buccola 
that  the  time  of  reaction,  taken  as  the  measure  of  attention,  is  like 
the  dynamometer  in  the  measurement  of  force,  and  with  De  Sanctis 
and  Janet,  that  the  method  does  not  merit  that  importance  that 
others  have  ascribed  to  it. 

However  this  may  be,  the  method  of  distraction,  by  which  the 
time  of  reaction  is  notably  modified,  may  give  important  results  for 
normal  and  pathological  psychology  and  for  pedagogy.  In  a process 
of  attention,  according  to  De  Sanctis,  we  must  consider  not  only  the 
power  of  accommodation  or  of  fixation,  but  also  that  of  distribu- 
tion or  the  extension  of  the  field  of  attention.  In  measuring  this 
field  we  may  take  into  account  the  aptitude  to  distribute  attention 
simultaneously  over  several  objects,  with  frequent,  strong,  and 
multiple  acts  of  volition,  and  the  greater  extension  of  the  field 
represents  the  pinnacle  of  evolution  of  the  attention,  ‘ provided 
that  in  distribution  it  maintains  at  a high  level  its  index  of  will- 
power, and  reaches  the  cognitive  effect  corresponding  to  every 
object  to  which  it  is  directed  ’ (De  Sanctis). 

Janet,  employing  the  concept  of  the  extension  of  attention,  has 
succeeded  in  demonstrating  that  there  exists  a relation  between  the 
power  of  attention  and  the  extent  of  the  visual  field.  This  re- 
lation would  explain  the  idea  of  the  extension  of  attention.  In  fact, 
while  the  concentration  of  attention  on  written  words  or  figures 
restricts  the  field  of  vision  in  sane  subjects  by  not  more  than  5 or 
10  per  cent.,  the  same  condition  produces,  in  some  morbid 
states,  a considerable  restriction,  sometimes  allowing  nothing  more 
to  be  seen  than  the  single  word  or  the  single  cypher  or  drawing 
in  the  centre  of  the  perimeter  (Janet,  Nevroses  et  I decs  fixes,  1898). 


PHYSIO-PATHOLOGY  OF  ATTENTION 


233 


Independently  of  the  causes  of  distraction  there  exist  physio- 
logical fluctuations  of  attention  in  the  case  of  stimuli  of  minimum 
intensity.  Lately  these  have  been  thoroughly  studied  by  Cook 
[Amer.  Journ.  of  Psychol.,  iSpP'iQOo),  whose  results  contradict  those 
of  Heinrich.  If  at  night  we  have  a small  watch  near  the  bed,  we 
do  not  notice  its  ‘ tick-tack  ’ continuously  ; it  seems  to  disappear  and 
reappear,  all  the  other  conditions  remaining  the  same.  Urban- 
tschitsch  explains  these  oscillations  by  the  weariness  of  the  external 
sensory  organ,  differing  from  Lange,  who  attributes  to  them  a central 
origin.  Miinsterberg  makes  them  dependent  on  the  muscles  of 
accommodation  ; H.  Eckener  (‘  Unter suchungen  tlber  die  Schwcin- 
kungen  der  Auffassung  minimaler  Sinnesreizenf  Annee  Psych., 
1889)  attributes  them  in  part  to  the  weariness  of  the  sensoiy  organ, 
in  part  to  the  persistence  of  the  representations  of  the  noise. 

A new  factor  for  the  interpretation  of  this  phenomenon  has 
been  introduced  by  A.  Lehmann,  who  has  discovered  a lelation 
between  the  oscillations  of  the  attention  and  the  phases  of  the 
respiration  and  the  bodily  adjustment.  As  is  well  known,  atten- 
tion induces  a notable  change  in  the  graphic  representation  of  the 
respiration  : thus,  oscillations  of  attention,  due  to  stimuli  of  hearing, 
sight,  touch,  are  more  frequent  during  the  pause  in  respiration, 
when  the  blood-pressure  in  the  brain  is  at  its  minimum,  and  at  the 
end  of  the  inspiration,  when  the  pressure  is  at  its  maximum.  That 
signifies  that  these  two  phases  of  respiration  are  less  favourable  for 
the  production  of  weak  sensations.  On  the  other  hand,  the  respira- 
tion, the  circulation  and  the  pressure  of  the  blood  undergo  notable 
changes  during  a state  of  attention.  A mental  calculation,  even 
though  it  last  only  a few  seconds,  produces  an  almost  constant 
acceleration  of  the  heart-beats,  and  increases  the  pressure  of  the 
blood  (Gley,  Binet  and  Courtier,  MacDougal).  The  power  of  atten- 
tion develops  with  advancing  years.  In  infancy  this  power  is 
sensory,  and  rises  by  degrees  to  the  strongest  will-power  in  the  adult 
man,  as  his  mental  equipment  increases  and  is  disciplined  in  con- 
sciousness. It  decays  in  old  age,  and  is  weakened  by  all  the  in- 
volutionary and  degenerative  processes  of  the  nervous  centres. 

The  pathology  of  the  attention  might  be  enriched  by  a very 
large  number  of  pathological  facts,  which  would  render  this  study 
very  interesting  were  I not  obliged  to  limit  myself  to  the  most 
important  and  most  frequently  recurring.  In  the  times  in  which 
we  live,  when  neurasthenic  conditions  have  become  so  prevalent 
and,  above  all,  from  the  methods  followed  in  our  secondary  schools, 
the  effects  of  which  are  felt  also  in  the  higher  schools,  where  the 
organization  is  such  as  to  cause  great  hurt  to  mental  vigour,  on  the 
very  eve  of  the  day  when  man  tries  his  strength  in  the  struggle  for 
life,  a struggle  in  which  the  youth  at  once  engages  when  his  studies 
are  over — the  fault  most  frequently  noted  is  the  incapacity  to  keep 
the  voluntary  attention  active  for  the  time  required  for  the  regular 


234 


PSYCHIATRY 


employment  of  one’s  own  activity.  The  most  general  complaint 
of  these  men  is  of  incapability  to  follow  the  thought  of  the  pro- 
fessor for  something  less  than  an  hour  without  having  their  atten- 
tion distracted,  or  to  maintain  a determined  order  of  ideas  in  con- 
sciousness for  a desirable  length  of  time.  It  may  be  that  their 
reading  resolves  itself  into  a useless  waste  of  time,  because  whilst 
they  read  their  consciousness  is  filled  with  many  other  extraneous 
ideas,  the  invading  power  of  which  grows  in  proportion  to  the 
diminution  of  the  power  of  attention,  which  ought  to  force  them  to 
the  perception  of  the  thought  contained  in  what  they  read.  Thus, 
after  reading  for  a longer  or  shorter  time,  they  do  not  know  what  the 
author  means  to  say,  and  are  obliged  to  begin  again  at  the  beginning, 
most  frequently  with  no  better  result. 

As  we  see,  we  are  here  dealing  with  diminished  power  of  deten- 
tion in  consciousness,  and  also  with  diminished  regulative  and 
selective  power.  This  latter  fails  because  everything  that  invades 
the  mind,  without  volition  of  the  subject,  and  often,  indeed,  against 
his  will,  is  not  repulsed.  It  breaks  freely  into  the  field  of  conscious- 
ness, taking  away  more  or  less  perceptive  power,  and  especially 
apperceptive  power.  We  have  here  two  facts  which  are  associated 
and  are  characteristic  of  this  pathological  state  : on  the  one  hand, 
the  incapacity  to  hold  in  consciousness  the  ideative  constellation 
that  is  the  object  of  voluntary  attention  ; on  the  other  hand,  the 
incapacity  to  keep  outside  of  consciousness  a number  of  other  ideas 
that  have  no  relation  to  the  preceding,  and  against  which  the  will- 
power of  attention  is  exercised  weakly  and  inefficiently. 

Fatigue,  to  whatever  cause  due,  produces  this  phenomenon,  to 
which  has  been  given  the  name  of  ‘ hypoprosessis  ’ — diminution  of 
attention — and  which  all  of  us  have  experienced,  not  excluding  men 
of  habitually  strong  reflective  power.  Sometimes  the  attention 
maintains  its  strength  on  the  concentrative  side,  and  diminishes  on 
the  distributive.  These  are  the  cases  of  so-called  distraction,  of 
which  we  can  recognise  two  types, — ‘ concentration  in  the  void  ’ and 
‘ concentration  on  a single  idea.’  Cases  in  the  last-named  class  are 
strongly  attracted  to  one  theme  or  one  thought,  are,  as  we  usually 
say,  absorbed,  and  cannot  bring  their  attention  to  bear  on  any  other 
subject.  This  phenomenon  is  often  observed  in  great  men. 

A strong  diminution  of  the  power  of  attention,  rather  on  the 
distributive  than  the  fixative  side,  is  produced  by  the  emotions. 
The  observations  of  Fere,  of  Binet,  of  Pick,  of  Mosso,  and  others, 
are  within  reach  of  all.  Fear,  rage,  hatred,  love,  jealousy,  immensely 
restrict  the  field  of  distributive  attention,  and  considerably  diminish 
that  of  concentrative  attention.  A healthy  and  regularly  evolved 
man  can,  in  ordinary  circumstances,  recall  to  mind  that  part  of  his 
mental  experience  that  pleases  him  most,  conformably  to  the  varied 
and  mutable  aims  in  life.  In  our  consciousness,  ideas  are  con- 


PHYSIO-PATHOLOGY  OF  ATTENTION 


235 


tinually  following  upon  one  another  and  are  as  continually  being 
renewed,  and  so  it  is  with  emotions  and  impulses,  some  of  which  we 
will,  others  not.  Some  of  these  invade  the  field  of  consciousness  by 
their  own  strength  and  subjugate  the  will;  others  come  into  con- 
sciousness because  we  have  willed  to  call  them  up  (voluntary  atten- 
tion). Thus  the  struggle  against  the  selective  power  of  consciousness 
is  revived  or  is  suspended,  giving  rise  to  voluntary  renewal  or 
forcible  invasion  of  ideas,  and  our  adaptation  to  those  that  obtain 
the  consent  of  the  will,  even  though  not  voluntarily  evoked,  thanks 
to  their  vibrating  in  harmony  with  the  personality  at  that  given 
time.  All  forms  of  nervous  weakness,  congenital  or  acquired,  are 
accompanied  by  more  or  less  accentuated  hypoprosessis. 

There  are  other  morbid  states  in  which  the  selective  capacity 
is  immensely  reduced  and  the  will  is  powerless  against  the  more 
or  less  importunate  guests  of  the  consciousness ; here,  attention  is 
impotent  against  the  intrinsic  power  of  the  unconsciousness,  which, 
despite  the  protest  of  the  will,  furnishes  useless  food  to  the  con- 
sciousness ; in  vain  does  the  will  invoke  the  aid  of  attention  ; for 
the  latter  has,  in  fact,  become  the  slave  of  that  mental  content 
which  the  will  seeks  to  drive  out  of  the  invaded  field  of  conscious- 
ness. Granted  that  the  power  of  attention  is  in  inverse  ratio  to 
the  psychic  automatism,  then  in  this  case  the  physiological  formula 
would  be  inverted,  owing  to  the  excessive  power  of  automatism  and 
the  detention  of  attention  in  consciousness,  in  opposition  to  the 
will.  Cases  of  so-called  fixed  ideas,  of  baseless  fears  (phobias),  of 
irresistible  impulses  with  their  resultant  acts,  and  of  irrational 
emotions,  offer  rich  material  for  the  observation  of  this  inverted 
law — inverted  at  the  cost  of  voluntary  attention. 

Some  consider  that  there  is  hyj)erprosessis  in  the  malady  of 
fixed  ideas.  Certainly  we  have  here  neither  voluntary  concen- 
trative  hyperprosessis,  because  in  these  cases  the  power  of  convoking 
images  in  consciousness,  of  selecting  and  eliminating  them,  is 
defective ; nor  distributive  hyperprosessis,  for  this  is  almost 
abolished.  On  full  consideration  we  shall  find  here  automatic 
sensory  hyperprosessis,  therefore  we  may  speak  of  hypoprosessis, 
and  so  avoid  falling  into  an  erroneous  interpretation  of  the  facts. 
The  predominance  of  automatism  is  revealed  also  by  other  facts 
related  to  those  previously  examined  and  referring  to  actions. 
The  most  common  case  is  of  those  errors  that  go  under  the  name 
of  lapsus  calami,  which  occur  oftenest  to  persons  who  are  fatigued, 
and  sometimes  with  such  frequency  as  to  cause  anxiety.  Words 
are  written  other  than  those  which  it  is  desired  to  write,  the  wrong 
word  generally  having  some  reference  to  an  idea  that  intrudes 
upon  the  consciousness  of  the  writer,  and  manages  to  resolve  itself 
into  the  corresponding  graphic  movement,  evading  the  directing 
power  of  the  attention.  At  other  times,  the  mind  of  the  writer 


236 


PSYCHIATRY 


passes  from  one  word  to  another  more  rapidly  than  the  hand, 
and  while  the  elementary  movements  required  for  the  formation 
of  letters,  syllables,  and  words  are  left  to  graphic  automatism, 
attention  directs  their  succession.  If  the  attention  fail  for  a 
moment,  then  automatism  takes  the  upper  hand  and  completes  a 
word  by  a syllable  or  a vowel  belonging  to  the  next  word,  omitting 
altogether  the  proper  ending  of  the  first. 

Sometimes  these  errors  happen  in  very  small  numbers  to  per- 
fectly normal  individuals,  by  reason  of  the  already  mentioned 
physiological  fact  of  oscillations  in  the  intensity  of  attention  ; or, 
as  others  put  it,  fluctuations  of  attention  to  elementary  sensations. 

All  neurasthenic  conditions  give  numerous  examples  of  such 
defects  of  attention. 

We  have  already  noted  that  attention  exercises  a selective 
power  upon  the  myriads  of  impressions  forming  matter  for  percepts, 
so  that  the  mind  is  enabled  through  attention  to  prepare  itself  to 
receive  from  among  the  number  only  those  that  have  special  interest 
for  it.  This  selective  power  diminishes  until  it  gradually  disappears, 
in  all  conditions  of  original  mental  debility — weak-mindedness, 
infantilism,  imbecility,  idiocy — or  in  cases  of  primary,  secondary,  or 
paralytic  dementia. 

The  most  conspicuous  examples  are  furnished  by  the  first  class — 
that  is,  by  cases  of  defective  and  incomplete  psycho-organic  evolu- 
tion. In  such  cases  the  sensory  or  involuntary  attention  is  awakened 
by  the  objects  that  fall  under  the  senses,  but  no  choice  is  effected  ; 
hence  those  sensory  reflex  movements  by  which  sufferers  under  this 
category  are  kept  in  continual  motion  towards  the  objects  them- 
selves. Here  we  have  reflex  sensory  processes  of  no  use  for  the 
increment  of  the  personality  ; also  more  or  less  complete  absence 
of  voluntary  attention,  and  therefore  of  apperceptive  power. 

The  same  defect,  more  or  less  accentuated,  is  met  with  in  all 
forms  of  mental  confusion  and  of  dementia,  as  well  as  in  all  con- 
ditions of  maniacal  exaltation  and  in  hallucinatory  forms  of  insanity. 
It  is  needless  to  add  that  in  these  different  cases  attention  is  faulty 
on  different  sides  of  its  mechanism.  In  mental  confusion  the 
attention  is  defective  owing  to  the  dissociation  of  ideas,  so  that  in 
consciousness  there  are  no  true  constellations,  but  only  a fragmen- 
tary residue  of  these,  and  detached  images  without  any  bonds  of 
association  ; and  upon  these  the  power  of  reflection  exercises  itself 
in  vain.  In  maniacal  exaltation  the  pleasurable  emotion  confers 
on  the  ideas,  and  on  the  content  of  consciousness  in  general,  an 
extreme  mobility  that  is  intolerant  of  detention,  while  there  is  a 
continual  discharge  to  the  motor  system  (psycho-motor  excitation). 
In  hallucinations  the  attention  is  occasionally  concentrated,  and 
may  be  fixed  for  a long  time  upon  the  hallucination,  so  that  the 
individual  appears  to  be  withdrawn  from  the  influence  of  external 


PHYSIO-PATHOLOGY  OF  ATTEYTIOY 


237 


stimuli,  thus  presenting  the  appearance  of  a state  of  distraction  or 
of  incapacity  of  sensory  or  voluntary  attention,  while  such  an  atti- 
tude corresponds  perfectly  to  the  law  of  intensity  of  stimulus.  In 
these  cases  we  may  speak  of  true  concentrative  hyperprosessis  for 
hallucinations,  and  of  hypoprosessis  for  real  objects. 

In  this  and  other  classes  there  are  cases  in  which  the  attention 
may  be  awakened,  in  which  we  recognise,  moreover,  a power  of 
attending  to  objects  and  a directive  and  selective  power  over  ideas  ; 
but  such  attention  is  soon  exhausted,  and  after  a few  propositions, 
the  automatism  of  the  images  assumes  the  upper  hand. 

There  is  always  a notable  defect  of  attention  in  that  form  of 
psychic  degeneration  characterized  by  impulsiveness  (congenital 
delinquency,  epilepsy). 

Besides  defects  of  attention,  there  exist  morbid  states  of  hyper- 
attention (hyperprosessis).  This  phenomenon  is  most  frequently 
met  with  in  paranoia,  in  hypochondria,  sometimes  even  in  melan- 
cholia, and  in  the  first  phase  of  hypnotism.  In  paranoia,  sensory 
disorders  are  most  frequently  the  effect  of  hyperattention  and  of 
preperception. 

WTien  the  paranoic  idea — the  fixed  idea — commences  its  work 
of  transforming  the  personality,  assuming  relations  and  bearing 
with  it  into  the  field  of  consciousness  all  other  ideas  that  are  somehow 
or  other  associated  with  it,  the  perceptive  territory  is  prepared  for 
weak  external  stimuli,  which  are  sought  out  by  the  paranoic  subject 
in  order  to  correlate  the  new  psychic  content  of  his  consciousness 
with  the  external  world. 

This  period  of  the  malady  is  characterized  by  expectant  atten- 
tion, which  sometimes  gives  rise  to  preperception  and  illusion, 
favoured  by  the  transforming  power  that  the  new  consciousness 
has  over  the  percepts.  In  this  illusory  transformation  of  the  per- 
cepts in  consciousness  we  have  one  of  the  most  important  attributes 
of  paranoia,  a trouble  which  keeps  the  attention  ever  vigilant  and 
intently  seeking  in  the  external  world  the  objective  proof  of  the 
new  facts  that  interest  the  personality  thus  menaced. 

So  it  is  also  in  hypochondria.  Slight  organic  sensations,  that 
pass  unnoticed  in  normal  states,  traverse  the  prism  of  prepercep- 
tion, and  fall  among  the  material  prepared  by  hyperattention, 
furnishing  matter  for  false  judgments  as  to  the  threatened  health. 
As  may  be  clearly  seen,  we  have  here  at  work  not  only  hyper- 
attention, operating  freely  on  external  and  internal  objects  as  they 
alternate,  but  also  a forced  unilateral  attention,  bound  to  the 
dominating  ideas  of  the  new  personality,  and  prepared  in  the  un- 
conscious for  the  beginning  of  a new  life — a life  with  false  relations 
to  the  external  world,  and  directed  towards  a theme  from  which 
attention  has  no  longer  any  power  to  detach  itself. 


238 


PSYCHIATRY 


Exalted  power  of  attention  is  also  met  with  in  states  of  passion. 
In  melancholia  and  in  the  first  phase  of  hypnotism  we  may  find 
examples  of  concentrative  hyperattention.  According  to  the 
observations  of  all  those  who  have  investigated  this  subject  (Haiden- 
hain,  Beard,  Schneider,  Richet,  Morselli,  Janet,  and  many  others), 
there  coincides  with  the  fixation  of  the  look,  in  the  first  period,  a 
hypnotic  suggestive  monoideism. 

Concentrative  hyperprosessis  can  also  be  recognised  in  ecstasy, 
and  has  its  counterpart  in  the  great  attention  that  infants,  savages, 
and  even  apes  pay  to  bright  and  shining  objects,  seen  for  the  first 
time. 


CHAPTER  III 


PHYSIO-PATHOLOGY  OF  MEMORY 

Closely  connected  with  the  subject  of  perception  and  with  its 
qualitative  and  quantitative  disorders  is  that  of  the  memory  and 
its  disturbances.  This  is  not  the  place,  however,  for  a long  and 
methodical  exposition  of  the  doctrines  of  the  psycho-physiology  of 
memory.  I shall  mention  only  in  what  memory  consists,  what 
constitutes  its  mechanism,  and  where  it  is  situated,  and  give  a few 
general  laws  that  govern  this,  the  most  important  and  substantial 
function  of  the  brain,  pointing  out  likewise  the  semeiological  value 
of  the  defects  and  disorders  of  memory  as  independent  factors,  and 
also  as  related  to  the  various  forms  of  mental  maladies. 

I have  already  said  that  no  stimulus  which  acts  upon  the  nervous 
system  fails  to  leave  behind  a trace  of  itself,  or  to  modify  the  system 
in  some  part  and  in  some  way  ; and  now  I mention  that  the  same 
modification  is  reproduced,  as  a whole  or  in  part  only,  under  the 
same  stimulus  or  under  analogous  stimuli.  This  is  the  general  law. 
I go  beyond  what  has  been  affirmed  by  Herbart  and  his  school, 
according  to  whom  perceptions  persist  in  the  mind  and  only 
apparently  disappear.  Memory  is  not  only  of  percepts,  but  also  of 
nervous  modifications  of  which  we  have  no  perception.  Whether 
the  stimulus  succeeds  in  determining  a state  of  consciousness  or 
merely  rests  outside  the  threshold  of  consciousness,  that  part  of 
the  nervous  system  that  has  been  subjected  to  the  action  of  the 
stimulus  has  been  modified  in  such  a way  that,  under  certain  con- 
ditions, this  same  modification  is  reproduced. 

The  ideas  of  Sergi  as  to  the  influence  of  the  repetition  of  the 
stimulus  can  mean  nothing  else  than  this,  for  he  thinks  that  the 
external  excitations  are  not  at  first  adapted  to  give  a definite 
sensation,  and  that  the  sensation  arises  through  a sort  of  adapta- 
tion to  the  excitations — that  is  to  say,  the  first  excitations  of  the 
series  have  sensibly  and  successfully  modified  the  part  of  the  ner- 
vous system  that  they  have  traversed,  so  as  to  facilitate  the  passage 
of  the  successive  stimuli,  which,  owing  to  the  diminished  resistance, 

239 


240 


PSYCH  I A TRY 


will  succeed  in  reaching  and  forcing  the  portals  of  consciousness, 
though  their  intensity  be  no  greater  than  that  of  their  predecessors. 

According  to  Adamkiewicz  also,  memory  has  no  psychic  char- 
acter in  itself.  He  advances  the  hypothesis  that  the  mnesic 
phenomenon  resembles  the  energy  by  means  of  which  a solution 
of  caustic  soda  absorbs  carbonic  acid  (myelopexia). 

Memory  is  therefore  defined  as  that  function  by  which  the  nervous 
system  receives^  conserves,  and  reproduces  impressions.  The  con- 
ditions under  which  memory  may  exist  are  those  known  to  biology  : 
regular  irrigation  by  the  blood,  and  normal  rechange  of  material, 
securing  the  efficient  nutrition  of  the  brain,  which  is  the  organic 
condition  indispensable  to  receptivity,  to  retentiveness,  and  to  re- 
production. 

It  is  necessary  to  go  more  fully  into  the  question  of  the  consti- 
tution of  these  various  elements  of  memory.  We  have  to  learn 
more  particularly  by  what  mechanism  reception,  conservation,  and 
reproduction  of  the  nervous  processes  are  effected  ; how  to  interpret 
the  phenomenon  of  recognition,  which  is  one  of  the  moments  of 
perception  ; what  is  the  mechanism  of  conservation  and  of  repro- 
duction, and  what  is  the  anatomical  basis  of  memory.  This  subject 
demands  our  attention  the  more  urgently  as  the  memory  is  a funda- 
mental property  of  the  nervous  substance,  without  which  no  other 
phenomena  of  the  mind  would  be  possible,  not  even  perception 
itself,  which  is  based  upon  recognition.  C.  Richet  wrote  well  to 
the  purpose  in  1886,  when  he  said  : ‘ Of  all  the  psychic  functions 
memory  is  the  most  important.  Without  memory  there  is  nothing 
in  the  intelligence,  neither  imagination  nor  judgment,  language, 
nor  consciousness.  It  may  be  said  of  the  memory  that  it  is  the 
keystone  of  the  intellectual  structure.’ 

We  commence  by  examining  in  more  detail  the  phenomena  of 
reception  and  of  conservation,  with  which  is  closely  connected  that 
of  reproduction.  In  what  do  these  consist  ?.  The  hypotheses  are 
more  or  less  probable,  but  they  cannot  be  subjected  to  any  manner 
of  experimental  control.  We  have  to  deal  with  a movement,  or 
with  a chemical  modification,  or  with  both  together,  as  in  any  other 
physiological  fact.  This  may  be  admitted  through  analogy. 

Except  Luys — who  maintains  the  doctrine  of  movement,  which 
admits  a vibration  of  the  nervous  element  under  the  influence  of 
external  stimuli,  the  nervous  element  being  brought,  as  it  were, 
into  a state  of  transitory  catalepsy — all  the  authorities  agree  on  the 
hypothesis  of  a molecular  or  atomic  movement  in  the  cell,  which 
is  difficult  to  conceive  of,  apart  from  a chemical  modification. 
Matters  have  not  advanced  beyond  the  point  reached  by  Maudsley, 
according  to  whom  the  same  nervous  current  is  reproduced  when 
the  same  idea  is  reawakened.  A material  and  atomic  modification, 
from  which  is  inferred  a persistent  modification  of  the  nervous 
element,  is  admitted  by  Hering  and  by  Delboeuf,  who  say  that  the 


PHYSIO-PATHOLOGY  OF  MEMORY 


241 


residuum  of  the  external  action  consists  in  a new  disposition  of  the 
molecules  of  the  nerve-cell ; also  by  Biewliet,  who  thinks  that  both 
simple  and  complex  images  formed  under  the  action  of  stimuli 
are  conditioned  to  a movement  that  alters  the  molecular  structure 
of  the  nerve-cell  for  a varying  period  of  time.  The  molecular 
structure  assumes  a new  arrangement,  facilitating  the  repetition 
of  the  movement,  and  in  its  turn  this  induces  a more  considerable 
deformation  of  the  cell  itself,  thus  insuring  a more  facile  reproduc- 
tion of  the  images. 

The  movement  that  has  taken  place  leaves  a trace  of  its  passage 
— the  disposition  trace.  Neither  the  pure  psychologists  like  Bain 
Ribot,  Sergi,  nor  the  physiologists  like  C.  Richet,  dissociate  them- 
selves from  the  concept  of  cell  modification.  Even  Wundt,  who 
will  not  admit  either  the  doctrine  of  Herbart  or  that  of  Delboeuf 
and  Biewliet,  recognising  only  the  disposition  to  reproduce  images, 
is  forced  in  the  end  to  allow  that  if  anything  is  reproduced  it  must 
have  remained  over,  in  some  form  or  other,  from  a quid  that  has 
modified  the  nervous  system  in  a permanent  fashion  in  some  par- 
ticular part.  It  is  useless  to  devote  longer  time  to  a subject  that 
is  decidedly  hypothetical,  and  about  which  everyone  may  be  re- 
peating the  same  thought  in  different  form. 

Receptivity. — By  this  word  is  understood  the  complete  action 
of  receiving  and  conserving.  About  receiving  we  have  said  all 
that  is  necessary  in  the  chapter  on  perception.  As  to  conserva- 
tion, we  shall  say  here  what  is  required  for  the  comprehension  of 
those  phenomena  that  will  most  directly  occupy  our  attention.  In 
order  that  the  physiological  fact  of  conservation  may  be  realized, 
it  is  necessary  in  the  first  place  that  the  anatomical  substratum 
of  perception  should  maintain  its  condition,  and  also  that  there 
should  be  a normal  state  of  all  those  factors  that  concur  in  main- 
taining the  integrity  of  the  anatomical  substratum  (nutrition, 
circulation,  etc.). 

On  the  other  hand,  conservation  is  ruled  by  many  of  the  laws 
of  perception,  which  it  is  needless  to  repeat  here.  The  time  re- 
quired for  perception  and  discernment  is  also  necessary  for  con- 
servation ; and  it  is  natural  that  if  the  stimulus  prolongs  its  action 
on  the  centre  of  perception,  other  things  being  equal,  the  con- 
servation of  the  images  formed,  and  of  their  derivatives,  will  be 
more  certain. 

The  intensity  of  the  impression  is  equally  a condition  of  the 
conservation  of  the  images,  which  is  bound  up  with  the  fact  of 
perception.  We  might  formulate  the  law  that  a percept  or  a 
secondary  product  due  to  association  will  be  all  the  more  surely 
conserved  the  more  perfect  the  perception. 

The  muscular  component  of  perception  and  attention,  and  there- 
fore the  muscular  memory,  have  a great  influence  on  memory  in 
general.  This  affirmation,  that  might  be  sustained  on  a priori 

16 


242 


PSYCHIA  TRY 


grounds,  for  the  very  evident  reason  that  the  more  extensive  the 
associations  the  more  enduring  is  the  memory,  has  been  subjected 
to  experimental  proof  by  L.  Smith.  It  will  be  well  to  recall  some 
of  his  experiments.  He  made  certain  individuals  repeat  a series  of 

ten  syllables  after  they  had  read  them  mentally  for  a fixed  time 

twenty  seconds.  This  reading  to  one’s  self,  as  is  well  known, 
induces  rudimentary  movements  towards  pronunciation.  On  alter- 
nate days  he  made  the  same  individuals  pronounce  the  num^bers 
I,  2,  3,  etc.,  while  they  were  reading  to  themselves,  on  purpose  to 
hinder  the  nascent  articulatory  movements  during  the  reading. 
The  syllables  were  repeated  after  seventy  seconds.  Of  course,  the 
number  of  m,ental  readings  varied  according  to  the  individuals 
during  the  twenty  seconds.  In  the  series  of  simple  memorizations 
(mental  reading)  the  number  of  errors  over  all  the  subjects  experi- 
mented upon  was  less  than  in  the  case  in  which  the  subjects  counted 
while  they  were  committing  to  memory.  In  the  latter  instance 
there  was  an  increase  of  error  of  12  to  17  per  cent. 

These  experiments  prove  what  a great  influence  on  mem^oriza- 
tion  is  exerted  by  the  motor  images  associated,  for  example,  with 
the  visual  images.  When  we  read  to  ourselves,  or  when  we  read 
aloud,  the  motor  images  are  associated  with  the  visual,  in  the  first 
case  as  nascent  movement,  in  the  second  as  effective  movement. 
If  the  visual  image  be  isolated  by  suppressing  the  muscular  im.age 
with  the  aid  of  suitable  experimental  methods,  as  was  done  by 
L.  Smith  (‘  On  Muscular  Memory,’  Amer.  Jour,  of  Psych.,  1896), 
the  number  of  errors  in  the  memorization  is  increased  by  10  to  22  per 
cent.  ; but  these  errors  prove  the  influence  of  distraction,  and 
therefore  of  attention,  upon  the  memory  more  than  they  prove  the 
influence  of  the  muscular  sense  on  the  memorization  ; and  Smith 
therefore  made  some  subjects  learn  a series  of  ten  designs,  such  as 
are  used  for  teaching  the  alphabet  to  deaf  mutes.  In  some  of  his 
experiments  (the  visual  series)  he  exposed  the  series  of  ten  to  view 
for  a fixed  time  ; in  others,  besides  the  sight,  he  made  the  subjects 
pass  their  fingers  over  the  drawing,  using  natural  movements 
(the  optic  motor  series).  In  the  last  experiments  the  errors  were 
10  to  22  per  cent,  less  in  number  than  in  the  visual  series. 

For  the  same  reason,  the  repetition  of  the  stimulus,  in  the  opinion 
of  some,  secures  the  conservation  of  its  psychic  products.  The 
repetition  takes  place  in  two  ways  : either  the  object  that  has 
made  the  impression  is  represented  at  different  times,  or  we  volun- 
tarily reproduce  in  our  minds  a certain  image,  in  order  the  better 
to  conserve  it.  Towards  securing  this  result,  voluntary  attention 
and  the  grade  of  participation  of  the  ego  in  the  objects  perceived 
make  large  contributions.  The  more  the  ego  is  interested  in  the 
object  of  perception,  or,  what  is  the  sanre  thing,  the  higher  the 
hitellectual-emotive  potential  that  accompanies  a perception  or 
its  deiivatives,  so  much  more  certcfin,  other  things  being  equal,  is 


PHYSIO-PATHOLOGY  OF  MEMORY 


243 


the  conservation  of  the  percepts,  of  the  secondary  composites,  and 
of  the  acts  to  which  they  have  given  rise . It  is  the  interest  awakened 
by  a certain  external  or  internal  attitude  that  attracts  the  voluntary 
attention,  which,  as  I have  said  before,  concurs  in  the  conservation. 

Repetition  of  the  perception  of  an  object  or  of  a person  does 
not  always  contribute  to  furnish  clear  concrete  images  in  corre- 
sponding numbers.  Taine  has  already  noted  the  fact  and  given 
a plausible  explanation  of  it  {Intelligence,  trois.  edition,  1878)  : 
‘ The  repetition  and  the  variety  of  our  experiences,’  he  wrote, 
‘ tend  to  render  the  images  less  precise.  If  we  see  a person  eight 
or  ten  tim.es,  the  outline  of  his  form  and  the  expression  of  his  face 
are  in  the  end  less  clear  in  our  minds  than  on  the  morning  after 
the  first  view.  The  same  thing  happens  with  a monument,  a street, 
or  a landscape  that  we  see  several  tim.es  at  different  hours  of  the 
day.  The  first  impression,  clear  enough,  becomes  less  exact  the 
second  tim.e.  When  the  image  of  the  object  perceived  tends  to 
come  up  again,  it  brings  with  it  all  the  others  with  which  it  is  asso- 
ciated, and  as  these  have  varied  at  different  times,  they  cannot  all 
arise  again  together.  Now,  if  these  concomitant  images  be  ex- 
cluded, still  they  have  a tendency  to  arise  again,  and  even  if  they 
do  not  secure  representation,  yet,  remaining  in  a nascent  state, 
they  will  form  what  is  called  in  ordinary  language  an  impression, 
which  may  be  strong  without  ceasing  to  be  vague.’  Philippe  has 
confirmed  this  idea  of  Taine  by  experiment  (Revue  Philosoph., 
1897).  He  agrees  with  the  concept  that  the  images  of  an  object 
are  less  precise  in  proportion  to  the  magnitude  of  the  sum  of  anterior 
representations  from  which  they  result  ; also  the  rarer  the  images 
or  percepts,  the  more  concrete  they  are.  On  the  other  hand,  if  the 
perceptions  have  been  numerous,  the  images  lose  their  precise  and 
individual  characters  and  become  general. 

These  researches  also  tend  likewise  to  bring  into  evidence  the 
relation  between  perception  and  memory. 

A well-developed  perception  is  bound  up  with  the  past  experi- 
ence of  the  individual.  It  is  true,  however,  that  not  all  perceptions 
involve  a mnemonic  image,  nor  is  a mnemonic  image  required  for 
recognition,  as  there  may  be  reference  solely  to  a quality  of  know- 
ledge or  to  the  simple  sentiment  of  recognition  (Bourdon  and 
Washburn). 

Sometimes  the  stimulus,  such  as  a simple  perception,  is  new  to 
the  organism,  and  so  does  not  require  a mnemonic  image,  but 
resolves  itself  into  an  emotion  rather  than  a cognition. 

The  sensory  provinces  of  the  cerebral  mantle  do  not  possess 
equal  powers  of  conservation.  As  a rule,  the  visual  memory  is 
stronger  than  the  aural  memory.  Experiments  made  upon  379 
pupils  by  A.  Kirkpatrick  (Psych.  Rev.,  1894)  demonstrate  the 
superiority  of  the  mem.ory  of  objects  seen.  Of  10  words  that  are 
heard,  6-85  are  rem.em.bered  ; of  10  words  read,  6-92  are  remem- 

16 — 2 


PSYCHIATRY 


244 

bered  ; of  10  objects  presented  to  view,  8-28  are  remembered — a 
larger  number  than  when  the  objects  are  named  without  being  pre- 
sented. This  proves  the  superiority  of  the  objective  method  of 
teaching  in  schools. 

Almost  in  complete  agreement  with  these  results  are  those  of 
the  investigations  of  Miinsterberg,  who  would  seem  to  have  proved 
that  the  mean  of  the  errors  is  31-6  per  cent,  in  the  exercise  of  the 
aural  memory  (repetition  of  figures  or  names  of  colours  pronounced 
by  other  persons  and  not  seen),  while  it  is  20-5  per  cent,  for  visual 
memory  (repetition  of  the  series  after  the  subject  has  seen 
them). 

Further,  the  beautiful  experiments  of  Whitehead  (‘A  Study 
of  Visual  and  Aural  Memory  Processes,’  Psych.  Rev.,  New  York, 
1896)  confirm,  in  the  main,  the  results  obtained  by  Miinsterberg. 
These  experiments  prove  that  with  vision  less  time  is  required  to 
fix  an  impression  than  with  hearing.  Below  are  two  columns  of 
figures  showing  the  times  required  by  different  subjects  for  learning 
visually  and  aurally  : 


Visual  Memory,  Aural  Memory. 


1-41  of  a 

second. 

2*38  of  a second. 

2-15  .. 

5 j 

1-52  33 

3 3 

2-i8  „ 

3 j 

2-32  „ 

3 3 

2-34  .. 

53 

2-54 

3 3 

2-35  ,, 

3 3 

2*37  .. 

33 

2*45  » 

33 

2-47 

33 

2-43  ,, 

33 

3*0  33 

33 

3*11  ,, 

3 3 

4*33  33 

33 

4-41  .. 

33 

4-42  „ 

Retentivity, 

however,  seemed  to  the  same 

writer  to  be 

stronger  in  the 

case  of 

matters  memorized  aurally.  Hawchins 

(‘Experiments  on  Memory  Types,’  Psych.  Rev.,  1897)  thinks  the 
aural  memory  stronger  than  the  visual  in  young  people,  and  he 
found  that  the  proportion  of  words  retained  by  children  between 
eight  and  twelve  years  varied  from  42  to  80  per  cent,  in  the  aural 
series,  and  from  30  to  65  per  cent,  in  the  visual  series. 

For  the  rest,  we  all  know  examples  of  special  memory  for  music, 
for  figures,  and  for  faces.  The  fact  of  the  facility  of  fixation  for 
certain  categories  of  impressions  in  some  senses  rather  than  in 
others,  is  proved  by  a long  series  of  observations — among  them 
those  of  Guicciardi  and  Ferrari,  on  the  mental  calculator  Zamboni. 

The  problem  of  retentivity — conservation — ^has  been  more  clearly 
stated  by  Ebbinghaus  in  this  question  : ‘ How  much  is  retained 
under  given  circumstances  ?’  He  made  a number  of  experimental 
researches,  through  which  we  have  arrived  at  a knowledge  oj  the 
different  capacities  for  conservation  of  motor,  acoustic,  and  visual 


PHYSIO-PATHOLOGY  OF  MEMORY 


245 


images,  and  some  combinations  of  them  (Cohn,  Whitehead  and 
T.  Smith,  Binet,  Galton). 

The  strongest  proof  of  the  difference  in  development  of  visual 
and  of  aural  memory  in  different  men  is  afforded  by  the  valuable 
researches  of  A.  Binet  in  his  study  of  the  memory  of  great  calcu- 
lators and  chess  - players  (Psychologic  des  grands  Calculateurs  et 
Joueurs  d'Echecs,  Paris,  1894).  As  is  well  known,  the  eminent 
chess-players,  who  play  from  a distance,  must  have  a great  visual 
memory  to  give  them  the  representation  of  the  chess-board,  the 
pieces,  their  colours,  and  their  relative  positions.  It  matters  little 
whether  this  is  concrete  visual  memory  or  abstract  visual  memory, 
as  Binet  says.  If  it  be  true  that  the  chess-player  does  not  repre- 
sent to  himself,  as  Taine  thought,  the  form  and  colour  of  the  piece 
as  in  a mirror,  also  the  positions  of  the  pieces  and  their  possible 
moves,  yet  it  is  none  the  less  so  that  this  memory  cannot  be  dis- 
tinguished from  the  other  concrete  memory  of  the  pieces  and  of 
the  chess-board.  What  these  men  possess  is  a form  of  geometrical 
visual  memory  that  has  already  been  described  by  many  writers. 

Others  furnish  examples  of  marvellous  aural  memory.  At 
fourteen  years  Mozart  wrote  down  from  memory  the  ‘ Miserere  ’ of 
Allegri,  after  hearing  it  but  once  in  the  Sistine  Chapel.  Such 
examples  might  be  multiplied. 

Conservation  varies  with  age,  as  is  shown  by  the  experiments  of 
Jacobs,  Bourdon,  and  others.  By  making  some  pupils  repeat  a 
certain  number  of  series  of  figures,  letters,  monosyllables,  dis- 
syllables, or  trisyllables,  immediately  after  hearing  them  pronounced, 
Bourdon  found  that  from  the  age  of  eight  upwards  the  pupils  made 
hardly  an  error  in  the  repetition  of  the  series  of  five  figures,  four 
monosyllables,  or  four  dissyllables  ; but  they  could  not  repeat, 
without  a remarkable  number  of  errors,  the  series  of  ten  figures,  ten 
letters,  or  eight  words.  This  power  of  immediate  memorization 
varies  between  eight  and  twenty  years.  Progress  is  most  rapid, 
however,  from  eight  to  thirteen  years,  and  is  barely  sensible  from 
fourteen  to  twenty.  Much  importance  is  to  be  attached  to  the  fact 
that  children  are  equal,  or  perhaps  superior,  to  adults  in  the  fixation, 
conservation,  and  recall  of  recollections ; but  adults  are  much 
superior  in  the  selection  of  what  they  will  remember — that  is  to 
say,  they  exercise  very  much  more  control  over  the  memory  by 
volition  than  children  do. 

Fixation  and  conservation  are  not  one  and  the  same  thing.  It 
is  quite  common  to  meet  with  individuals  endowed  with  ready  and 
facile  perception,  and  who  consequently  learn  much  and  learn  it 
quickly,  but  who  do  not  retain  it  long  or  well  ; whilst  there  are 
others  who  require  more  time  to  learn,  but  conserve  the  impressions 
and  cognitions  for  a very  long  time.  Of  these  people  we  say  that 
they  have  a faithful  and  tenacious  memory.  Facility  of  fixation 
and  also  of  conservation  depends  not  only  on  the  circumstances 


246 


PSYCHIATRY 


already  mentioned,  but  also  on  the  congenital  aptitude  of  the 
individual  to  retain  certain  classes  of  images  in  preference  to 
others. 

Two  other  questions  have  now  to  be  examined  : 

1.  What  is  it  that  is  conserved  ? 

2.  In  what  part  of  the  brain  is  it  conserved  ? 

The  first  question  is  in  part  included  in  what  we  have  already 
said  in  our  general  observations  on  the  memory.  It  is  well  to 
confess,  however,  that  we  do  not  know  the  true  nature  of  the 
cellular  or  reticular  modification  that  is  the  certain  physiological 
fact,  which  we  must  absolutely  presuppose  if  we  are  to  be  able  to 
form  even  an  empirical  conception  of  conservation  in  memory. 
From  the  anatomico-physiological  point  of  view,  we  must  of  neces- 
sity admit  that  the  modification,  whether  dynamic,  physical,  or 
chemical,  that  arises  in  the  nerve-cell  or  in  a zone  of  neuro-fibrillar 
reticulum  is  permanent,  though  perhaps  in  its  continuance  it  is 
less  intense  than  immediately  after  the  action  of  the  stimulus  ; but 
it  does  persist,  for  the  reproduction  of  what  was  once  perceived 
would  be  quite  inconceivable  were  there  not  a certain  degree  of 
permanence  in  the  modification  effected  on  a certain  part  of  the 
central  nervous  system  under  the  action  of  the  stimulus. 

It  will  be  well  to  glance  over  the  hypotheses  that  have  been  put 
forward  on  this  subject.  What,  however,  is  needful,  rather  than 
merely  useful  to  know,  is  that  we  are  able  to  remember  not  only  what 
is  furnished  by  the  senses  in  the  form  of  images  of  the  external 
world,  but  also  the  secondary  products  of  percepts  in  the  infinite 
combinations  to  which  they  may  give  rise  in  the  field  of  conscious- 
ness and  in  the  unconscious. 

Mental  life  would  be  simple  enough  if  there  remained  fixed  only 
the  external  stimuli  that  have  resulted  in  images  on  the  cortex  of 
the  brain,  but  it  is  certain  that,  besides  these,  all  the  secondary 
products  derived  from  the  inhnitely  numerous  combinations  that 
each  image  enters  into  with  the  mental  content  of  the  individual 
are  likewise  fixed  and  conserved.  Further,  the  same  happens  with 
all  the  emotive  states  provoked  by  single  stimuli  in  the  most  widely 
different  conditions  of  mind.  Here,  naturally,  we  observe  a greater 
variety,  and  this  has  given  rise  to  contradictory  assertions.  As 
the  emotive  states  are  not  so  easily  reproduced  as  images  and 
thoughts,  some  have  maintained  that  they  cannot  be  reproduced 
at  all. 

The  solution  of  the  psychological  problem  is  not  easy.  The 
examples  adduced  by  Ribot  and  by  Titchener  are  not  convincing 
either  one  way  or  another.  How  are  we  to  separate  the  emotive 
element  from  the  ideative  element  in  recollection  ? If  a jealous 
woman  groans  as  she  thinks  of  the  estranged  love  of  her  husband. 


PHYSIO-PATHOUKrY  OF  MEMORY 


247 


or  his  mistress  ; if  a father  is  moved  to  tears  when  his  mind  recurs 
to  a recent  illness  that  almost  brought  him  to  the  grave  ; if  a soldier, 
as  he  recalls  the  past,  feels  the  emotions  of  a disastrous  battle  in 
Africa,  and  is  elated  by  his  own  heroism,  then  the  jealousy,  fear, 
and  pride  are  reproducible  only  through  a series  of  concrete  images 
with  which  they  are  associated.  It  will  be  the  image  of  the  mistiess 
or  of  some  other  woman  that  awakens  the  emotion  of  jealousy  , it 
will  be  one  of  the  numberless  images  which  disturb  the  mind  of  the 
father  who  is  anxious  for  the  welfare  of  his  children  that  causes 
the  flow  of  tears,  especially  at  a short  interval  after  the  danger  has 
passed  ; it  will  be  one  of  the  many  episodes  of  a battle,  passing 
momentarily  over  the  field  of  consciousness,  that  will  re-evoke  the 
emotions  of  that  memorable  day.  As  we  see,  the  ideative  com- 
ponent is  never  wanting,  and  that  renders  the  solution  of  the 
problem  very  difficult. 

There  remains,  however,  the  fact  that,  after  all,  the  emotions 
are  not  so  well  conserved  as  concrete  images  and  thoughts,  and  so 
our  thoughts  can  be  recalled,  dissociated  from,  and  tending  always 
to  be  more  completely  dissociated  from  their  strong  emotive  colour- 
ing. Notwithstanding  the  efforts  of  Ribot  to  convince  us  of  the 
conservation  and  therefore  the  reproducibility  of  emotion,  it  is 
my  opinion  that,  except  in  certain  morbid  states  in  which  the 
emotional  potential  prevails  over  the  ideative,  we  are  bound  to 
incline  to  the  opposite  doctrine,  held  by  Titchener  and  others— 
namely,  that  an  emotional  state  is  conserved  and  is  reproduced 
only  in  so  far  as  it  is  associated  with  intellectual  formations,  and 
it  is  evoked  by  the  representation  of  these  latter. 

I have  excepted  morbid  states,  but  there  may  also  be  an 
association  that  escapes  the  immediate  psychological  examination 
of  the  subject.  It  is  in  this  way  that  we  are  able  to  explain  the 
case  mentioned  by  Pardo  of  a medical  friend  who  was  obliged  to 
rise  in  the  middle  of  the  night  for  several  weeks  to  assist  his  sick 
father.  Some  time  afterwards,  when  called  during  the  night  to 
start  early  with  a picnic  party,  he  suffered  the  same  anguish  as  when 
he  was  awakened  to  assist  his  father.  This  is  an  example  of  le- 
production  of  the  emotion  without  any  ideative  representation,  but 
in  this  case  the  association  is  of  the  hour  with  the  recollection  of  his 
suffering  father  that  had  remained  in  the  unconscious.  We  all 
know  that  certain  emotions  are  habitually  associated  with  certain 
hours.  This  notion  has  been  clearly  expressed  by  the  great  Italian 
poet  : 

‘ Era  gia  V ora  che  volge  il  disio 
Ai  naviganti  c intcncriscc  il  cuorc 
Lo  di  c’  han  detto  ai  dolci  amici  addio.’ 

Nor  can  we  exclude  an  imaginative  association  in  the  case  of 
Toulouse’s  patient.  This  was  a case  of  amnesia  retro-anterogiada, 
produced  by  great  mental  suffering  in  a young  woman.  While 


248 


PSYCHIATRY 


incapable  of  fixing  actual  impressions,  or  of  having  ideative  recol- 
lections of  a fixed  period  of  time,  she  refused  to  go  and  see  Dr, 
Toulouse,  hinting  vaguely  that  he  had  acted  improperly  towards 
her,  because  on  her  first  visit  he  had  raised  her  clothes  in  order  to 
examine  the  knee  reflexes.  To  me  there  seems  to  be  very  little 
probability  in  the  interpretation  given  by  Toulouse  when  he  says 
that  it  was  not  the  actual  recollection  of  his  treatment  that  had 
offended  her,  but  the  recollection  of  the  disagreeable  emotion  that 
attended  it.  As  a matter  of  fact,  the  raising  of  the  garments  m,ay 
give  rise  to  an  idea  of  carnal  violation,  or  of  an  offence  to  honour, 
and  it  is  this  second  psychic  product,  which  is  intellectual-emotive, 
that  is  fixed.  At  the  same  time,  the  recollection  of  the  act  cannot 
be  excluded. 

It  is  certain  that  the  greater  portion  of  the  emotion  disappears, 
but  all  the  stronger  participations  of  the  ego  in  the  perceptive  or 
intellectual  movement  are  commemorable.  On  this  point  poets 
and  psychologists  are  at  one.  By  the  side  of  the  residua  of  per- 
ceptions we  must  place  the  residua  of  emotions  and  of  reactions, 
with  this  difference,  -that  mnemonic  reproducibility  is  at  its 
maximum  in  the  former  and  at  its  minimum  in  the  latter. 


As  to  the  seat  in  which  the  so-called  images  are  conserved,  I 
have  already  said  enough  on  this  point  in  the  chapter  on  percep- 
tion. For  many  years  I have  maintained  that  concrete  images  are 
the  products  of  the  combination  of  elementary  images.  From,  this 
point  of  view  the  hypothesis  of  Sergi  and  of  Ribot  as  to  the  physio- 
logical associations  in  the  process  of  perception,  and  therefore  also 
in  the  processes  of  conservation  and  reproduction,  is  up  till  now 
the  best  founded  and  the  most  probable  that  has  been  put  forward. 
By  the  same  general  law,  which  is  the  foundation  of  every  doctrine 
of  memory,  those  same  anatomical  elements  to  which  the  stimmlus 
has  arrived  under  the  form  of  a nerve-wave,  in  virtue  of  its  physical 
properties — those  same  elements  that  underwent  the  special  physio- 
logical modification  required  for  the  formation  of  the  elementaiy 
components  of  concrete  images — must  also  concur  in  reproduction  ; 
and  the  elements  formative  of  these  concrete  im,ages  are  also  the 
conservers  and  the  reproducers  of  the  images  and  their  components. 
The  doctrine  of  Munk,  Wilbrand,  Henschen,  Vialet,  of  the  trans- 
mission of  images  from  the  anatomical  elements  of  formation  to 
those  of  conservation,  although  it  has  also  been  maintained  recently 
with  singular  warmth  by  Sollier,  has  no  solid  foundation.  The 
duplicates  of  the  elementary  components  of  images  migrate,  so  to 
speak,  in  order  to  combine  with  others  and  constitute  a concrete 
image  ; further,  the  duplicates  of  the  concrete  images  migrate  to 
a common  field,  where  the}^  come  together  to  form  new  combinations 
and  images  of  a higher  order,  such  as  those  of  the  words  that  express 


PHYSIO-PATHOLOGY  OF  MEMORY 


249 


them,  and  of  the  abstract  concepts  of  which  these  are  elementary 
components.  In  this  continuous  movement  of  images  and  of  their 
components  we  have  the  key  of  intellectual  life  ; but  to  affirm  that 
images  are  formed  at  one  point  and  conserved  at  another,  from  which 
they  are  re-evoked,  appears  to  me  a most  arbitrary  hypothesis,  wdth 
little  shade  of  probability. 

Wundt  supposes  a general  organ  of  apperception,  which  is  the 
frontal  lobe,  and  particular  centres  that  are  incapable  of  registering 
images,  but  capable  of  retaining  the  disposition  to  reproduce  them, 
w’hich  is  thus  reduced  to  a functional  tendency  of  the  central  ner- 
vous elements  that  have  once  already  undergone  modification 
induced  by  external  stimuli.  The  centre  of  conservation  is  theie- 
fore  the  centre  of  apperception. 

Sergi  does  not  attempt  to  define  the  seat  of  conservation,  but 
pays  attention  only  to  the  most  general  facts  of  perception  and  of 
conservation,  in  which  every  observer  may  recognise  a great  deal 
of  truth,  except  perhaps  in  details.  He  holds  that  if  the  excitation 
of  the  nervous  elements  were  to  last  for  a long  time,  they  would  be 
w'earied  out.  External  excitations  do  not  give  a definite  sensation 
except  wffien  they  are  repeated,  and  the  sensitive  elements  both  of 
the  centres  and  of  the  periphery  adapt  themselves  to  the  actual 
excitation.  The  nervous  elements  of  the  periphery  and  of  the 
centres  are  thus  associated  for  a determined  form  of  sensation,  and 
they  adapt  themselves  to  this  special  mode  of  excitation,  become 
specialized,  and  so  give  rise  to  cerebral  localization.  It  is  the 
internal  central  excitations  that  persist  and  that  are  conserved  and 
reproduced.  This  process — special  to  reproduction — which  awakens 
a group  of  perceptions  associated  by  means  of  a perception  that  has 
been  directly  provoked,  he  calls  induction,  whence  the  law,  formu- 
lated by  him,  of  the  induction  of  perception.  This  law  is  based 
on — 

1.  The  habitual  modes  of  psychic  manifestations,  and,  conse- 
quently, 

2.  Localization  in  the  element  that  is  active. 

3.  Association  of  functional  elements  corresponding  to  the 
association  of  the  perceptions. 

4.  The  provocation  at  the  periphery,  or  at  the  centre,  of  one  of 
the  perceptions  of  the  associated  group,  or  the  excitation  of  a func- 
tional element  of  the  associated  group. 

According  to  Sergi,  therefore,  conservation  takes  place  in  the 
same  associated  groups  of  nervous  elements  in  which  the  percep- 
tions arose.  Sollier  does  not  allow  that  this  happens  in  the  same 
nervous  component  as  the  perception.  He  criticises  the  hypothesis 
of  Richet,  and  expresses  himself  as  follows  : 

If  A*  w^ere  really  modified  at  each  excitation,  as  happens  with 
a muscle,  memory  would  be  abolished.  As  a matter  of  fact, 
* Here  A stands  for  the  nervous  element. 


250 


PSYCHIATRY 


the  excitation  H reaches  the  cell  A and  modifies  it,  so  that  it  becomes 
A',  To  this  state  A'  there  corresponds  the  representation  that 
we  have  of  H,  which  we  shall  designate  by  a.  In  order  that  a may 
be  awakened  in  ns  and  may  constitute  a recollection,  it  is  necessary 
that  the  state  A',  to  which  it  corresponds,  be  itself  reproduced. 
Now,  this  does  not  happen  if  we  admit  with  Richet  that  a new 
excitation  H,  identical  with  the  one  that  produced  A',  modifies 
the  cell  A'  and  transforms  it  into  A". 

The  representation  a,  the  psychic  equivalent  of  H,  can  no 
longer  correspond  to  this  modification.  Instead,  there  will  be  a 
new  representation,  a'.  In  this  way  H,  exciting  the  same  cell, 
will  be  successively  represented  in  the  mind  by  a and  a' . 

If  A"  is  substituted  for  A',  just  as  A'  was  substituted  for  A, 
admitting  that  the  state  A'  can  never  be  reassumed  by  the  cell  A, 
it  is  impossible  to  understand  how  the  image  a could  reappear. 
Its  place  is  taken  by  a'  just  as  the  cell  A'  is  replaced  by  the  ceil  A". 

This  critical  conception  of  Sollier  has  a great  value,  and  even 
an  appearance  of  truth.  But  the  clear-sighted  psychologist  has 
not  given  due  consideration  to  the  fact  that  in  memory,  as  in  the 
successive  perceptions,  we  are  dealing,  not  with  a single  nervous 
elem_ent,  but  with  associations,  which  are  always  different  in  suc- 
cessive periods  of  time.  This  fact  is  connected  with  the  changing  con- 
ditions of  the  consciousness  and  of  its  content  in  each  unity  of  time. 

If  we  adopt  this  mode  of  interpreting  the  phenomenon  of  per- 
ception and  that  of  memory,  we  must  substitute  for  Sollier’s  formula 
another,  into  which  enters  the  element  of  association  ; and  in 
this  case,  if  we  represent  the  associative  potential  by  N,  we  shall 
hnd  that  A,  modified  the  first  time  and  transformed  into  A', 
reappears  always  in  the  same  identical  manner  under  the  influence 
of  identical  stimuli,  is  not  transformed  into  A",  and  therefore 
cannot  be  substituted.  The  recognition  is  connected  with  the  other 
component  N in  such  a way  that  in  the  successive  stimulations 
we  shall  have  A'N,  A'N',  A'N",  A'N'",  and  so  on. 

If  this  is  the  case,  the  condition  of  memory  is  not  oblivion,  as 
Ribot  says  ; but  memory  depends  upon  the  infinite  associative 
formations,  to  which  each  anatomical  component  makes  its  own 
proper  contribution,  corresponding  to  its  specific  function,  which 
it  has  formed  and  conserved  throughout  all  the  successive  forma- 
tions under  the  influence  of  the  external  and  internal  stimuli  con- 
ditioning the  phenomenon  of  recognition  and  reproduction. 

Recognition,  one  of  the  components  of  perception,  through 
which  a percept  is  put  into  relation  with  another  at  a different  time, 
is  to  be  interpreted  through  the  historic  process  of  consciousness, 
the  content  of  which  varies  at  each  moment  of  time,  while  it  is  into 
this  content  that  the  new  percept  must  be  received. 

Another  argument  favoured  by  the  upholders  of  a centre  of 
conservation  distinct  from  the  centre  of  perception,  is  drawn  from 


PHYSIO-PATHOLOGY  OF  MEMORY 


251 


the  disproportion — due  to  a false  calculation — between  the  number 
of  percepts  and  the  number  of  cells  in  the  mantle  of  the  brain. 
The  number  of  perceptions  is  calculated  by  some  at  about  20,000,000 
per  annum.  If  in  one  day  we  are  conscious  of  54,000  excitations 
received,  in  a year  that  amounts  to  20,710,000,  and  in  sixty  3^ears 
we  should  have  1,242,600,000,  a figure  which,  according  to  Sollier, 
is  almost  equal  to  the  number  of  nerve  cells  of  the  brain  ; but 
according  to  the  most  recent  researches  of  Hammarberg,  confirmed 
by  Thomson,  these  cells  amount  to  9,200,000,000,  a number  much 
superior  to  that  of  the  percepts  that  a sane  man  can  form  through- 
out his  whole  life. 

The  greatest  difficulty  arises  when  we  consider  the  very  large 
number  of  secondary  formations  which  can  be  fixed  and  conserved 
like  the  percepts. 

When  we  consider  that  thousands  of  combinations  can  be  formed 
with  a very  few  numbers,  those  that  are  possible  with  hundreds  of 
millions,  and  with  an  almost  infinite  number  of  secondary  products, 
are  beyond  the  powers  of  the  strongest  arithmetical  imagination. 
But  this  difficulty  is  not  avoided  by  the  doctrine  of  transmission, 
which  is  preferred  by  a select  number  of  physiologists  and  psycho- 
logists in  all  countries. 

Those  who  favour  this  doctrine  maintain  that  the  conservation 
of  impressions  is  not  possible  in  the  centre  of  perception  ; that  the 
conservation  of  images,  and  therefore  of  their  records,  takes  place 
in  another  part  ; and  that  when  the  perceptive  centre  is  destroyed, 
these  persist,  only  they  cannot  manifest  themselves.  This  may  lead 
them  to  hold — as,  in  fact,  they  do  hold — that  the  so-called  percep- 
tive centres,  described  in  detail  in  the  first  part  of  this  work,  are  only 
centres  of  reception  of  excitations  from  the  periphery,  and  that 
their  function  is  to  transform  the  excitations,  so  as  to  render  them 
suitable  to  be  received  in  the  first  place  and  evoked  afterwards. 

This  doctrine  cannot  be  maintained  ; it  contradicts  all  the 
postulates  of  physio-psychology  on  an  anatomical  basis.  Every 
operation  of  the  cells  under  external  or  internal  stimuli  leaves  a 
trace — chemical,  physical,  or  dynamic.  This  trace  is  the  funda- 
mental fact  of  memory,  and  is  translated  into  a specific  dynamic 
potential,  which  the  nervous  element  furnishes  whenever  it  comes 
into  a condition  identical  with,  or  analogous  to,  that  in  which  it 
assumed  relations  with  the  external  world  and  with  the  other 
anatomical  components  of  the  brain.  The  product  of  which  it  is 
capable  under  the  influence  of  external  stimuli  is  always  the  same 
by  nature,  but  enters  into  combination  with  other  products  through 
the  infinite  associative  paths,  uniting  with  one  another  the  various 
elements  in  the  brain. 

Sollier  establishes  an  analogy  between  this  conservation  and 
the  magnetization  of  a strip  of  steel.  The  capacity  for  magnetiza- 


252 


PSYCHIATRY 


tion,  just  like  the  receptivity  of  the  brain,  does  not  increase  beyond 
certain  limits  ; it  diminishes  with  time,  just  as  our  recollections 
grow  weak,  and  it  is  maintained  in  force  if  a piece  of  nonmagnetized 
steel  is  placed  in  contact  with  the  magnet,  in  the  same  way  as  a 
recollection  retains  all  its  clearness  if  it  be  left  in  contact  with  an 
impression  that  is  associated  with  it.  To  me  it  seems  probable 
that  images  can  be  transmitted,  as  words  are  transmitted  from 
apparatus  to  apparatus  by  telegraphic  wires. 

We  shall  see  shortly,  when  we  come  to  speak  of  evocation,  how 
we  interpret  evocation  in  any  region  of  the  brain  that  is  not  the 
region  of  conservation,  and  how  little  probability  attaches  to  the 
affirmation  of  those  who  locate  the  seat  of  conservation  and  of 
evocation  in  the  frontal  lobe. 


Reproduction  is  divided  into  two,  according  to  time — evocation 
and  reproduction,  properly  so-called.  Evocation  precedes  repro- 
duction, and  is  voluntary  or  involuntary.  Every  percept,  like 
every  image  that  is  formed,  evokes  other  images,  with  which  it  has 
associative  relations  of  various  natures.  Over  this  phenomenon 
the  will  does  not  exercise  absolute  and  exclusive  power.  The 
music  of  a pianoforte  heard  at  a distance  arouses  numberless  aural 
and  visual  images  ; the  song  of  the  nightingale  evokes  the  visual 
image  of  the  winged  nocturnal  singer,  of  the  night,  of  the  forest,  etc.  ; 
a gun-shot  heard  at  night  calls  up  an  infinity  of  images  and  of 
emotions.  These  are  examples  of  involuntary  evocation,  and  we 
may  formulate  the  law  that  every  image,  at  the  moment  it  pene- 
trates the  field  of  consciousness,  exercises  evocative  power  over 
other  images,  independently  of  the  will.  Such  power  varies  in 
degree,  according  to  the  intensity  or  to  the  vivacity  of  the  image, 
according  to  the  existing  patrimony  of  percepts  and  secondary 
products,  and  according  to  the  emotive  exponent  of  the  image  itself 
and  of  the  subject. 

\^oluntary  evocation  consists  in  a conscious  and  voluntary 
direction  of  the  mind  towards  the  premeditated  recall  of  a deter- 
mined image,  of  things,  persons,  relations,  places,  events  or  verbal 
images,  such  as  names,  verbs,  concepts,  etc.  In  this  the  will  is 
not  always  fortunate,  for  even  though  we  know  that  we  possess  the 
object  of  the  evocation,  hidden  momentarily  among  the  infinite 
coils  of  oblivion,  it  may  be  deaf  to  the  most  anxious  evocatory 
efforts  of  the  will,  and  evade  the  most  active  search  of  our  labouring 
desires. 

It  appears  clear,  therefore,  that  involuntary  evocation  is  per- 
formed by  some  active  point  of  the  cerebral  mantle,  and  that  volun- 
tary evocation  is  performed  by  that  psychic  component  fixed  by 
the  will  in  the  field  of  consciousness.  As  it  ma}^  be  visual,  aural, 
tactile,  etc.,  the  respective  area  will  be  the  evocative  centre.  Most 


PHYSIO-PATHOLOGY  OF  MEMORY 


253 


frequently,  however,  it  is  intellectual  syntheses  and  abstract  con- 
cepts that  demand  for  their  development  the  representation  of  the 
infinite  images  from  which  they  have  resulted,  and  in  this  case  the 
frontal  lobe  is  the  evocative  centre. 

According  to  a certain  psychologist,  the  image  is  evoked  at  the 
point  of  conservation,  and  reproduced  at  the  point  of  formation. 
Here  I have  pleasure  in  reproducing  the  words  of  Sollier  : ‘ . The 

centre  of  reception  becomes  the  intermediary  between  the  subjective 
state  and  the  objective  state,  and  when  it  happens  to  be  destroyed, 
the  reciprocal  transformation  of  the  one  into  the  other  can  no  longer 
take  place.  Recollection  can  therefore  have  its  seat  in  a part  dis- 
tinct from  the  centre  of  reception,  and  so  may  not  be  able,  when  this 
centre  is  destroyed,  to  manifest  itself  under  an  objective  form.’ 
And  further  on  : ‘ . . .For  the  moment,  what  we  must  bear  in 
mind  is  that  the  centres  of  perception  are  in  reality  only  centres  of 
reception  of  the  excitations  at  the  periphery,  necessary  for  the 
transformation  which  renders  them  fit  to  be  perceived  and  after- 
wards evoked  ; but  these  centres  are  not  the  seat  of  the  perceptions 
or  of  recollections.’  According  to  Sollier,  therefore,  the  impres- 
sions on  their  passage  do  not  leave  the  respective  images  in  the 
sensory  centres,  or  centres  of  reception,  as  he  calls  them.  These 
centres  are  destined,  instead,  to  subject  peripheral  excitation  to 
that  transformation  which  fits  it  for  perception  in  consciousness. 

Some  assume  that  the  frontal  lobe  is  the  field  of  conservation, 
and  therefore  of  evocation.  It  is  difficult  to  understand  why  the 
frontal  lobe  should  be  the  organ  for  conserving  and  evoking  images. 
Here  arises  logically  the  question  of  the  disproportion  between  the 
number  of  nervous  elements  and  the  number  of  images,  and  the 
solution  of  that  question  on  this  basis  could  only  be  disastrous  to 
such  a doctrine. 

All  images  are  conveyed  to  the  frontal  lobe,  not  to  be  deposited 
there  just  as  they  are,  but  to  enter  into  combination  with  others 
in  order  to  constitute  more  complex  psychic  products,  in  the  same 
way  as  the  elementary  components  of  single  images  meet  on  a 
different  field  to  form  a concrete  image.  Every  time,  therefore, 
that  a thought  arises,  there  comes  an  order  from  the  frontal  lobe  to 
the  separate  organs  that  form  and  conserve  the  concrete  images 
of  objects  and  of  words,  to  bring  forward  all  their  products  of  con- 
crete images  for  the  development  of  the  concept  of  which  these 
are  elementary  components.  When  I propose  to  myself  to  give  a 
lesson  or  a series  of  lessons  on  the  nerve-cell,  I have  only  the  abstract 
or  complex  concept  of  the  nerve-cell.  The  part  descriptive  of  the 
cell  is  referred  to  a greater  or  smaller  number  of  visual  concrete 
images  and  of  verbal  images,  which  have  their  proper  seat  at  the 
place  of  their  formation. 

In  this  case,  evocation  starts  from  the  abstract  concept,  and  is 
turned  upon  all  the  direct  and  collateral  components  from  which 


254 


PSYCHIATRY 


the  formed  concept  results.  This  example  will  instruct  us  still  | 
further.  If,  while  I am  reproducing  the  images  of  the  various  parts  | 
out  of  which  the  nerve-cell  is  constructed,  I give  each  one  of  these  | 
its  proper  name,  we  have  reproduction  of  phonetic  and  kinaesthetic  ! 
images  that  are  not  in  that  moment  recalled  by  the  frontal  lobe,  or,  | 
as  we  should  say,  by  the  abstract  concept,  but  directly  by  the  ! 
separate  visual  images  of  the  components  of  the  nerve-cell,  each  one 
of  which  is  associated  with  the  verbal  image  of  the  word  that  sym- 
bolizes it.  The  ' tick-tack  ’ of  the  clock  or  the  strokes  of  the  morning 
bell  give  me  immediately  the  visual  image  of  the  clock  or  bell,  as 
the  case  may  be,  as  well  as  a vision  of  the  breaking  day,  and  also  the 
words  for  all  these  things.  The  evidence  of  these  facts  obliges  us 
to  formulate  the  general  law  that  any  point  of  the  brain  reproducing 
its  own  content  in  consequence  of  a stimulus,  external  or  internal,  is  an  , 
evocative  centre  of  all  those  psychic  and  physiological  products  with 
which  its  own  product  stands  in  any  relation  whatsoever.  At  the  | 
utmost  we  may  speak  of  the  different  evocative  power  of  the  frontal  j 
lobes  and  of  the  sensory  zones,  properly  so-called.  The  frontal  1 
lobes  and  the  evolutive  zones  exercise  their  power  of  evocation  over  I 
the  whole  surface  of  the  brain,  whilst  the  power  of  the  other  zones  ! 
is  either  limited  to  one  or  two  sensory  areas,  or,  if  it  be  exercised  ! 
over  a much  more  extensive  field,  this  is  due  to  the  awakening  of  | 
generic  or  abstract  concepts,  which  in  their  turn  re-evoke  their’: 
elementary  components  over  all  the  cerebral  mantle.  i 

Another  argument  is  adduced  in  support  of  a distinct  centre  of  jj 
evocation  in  the  frontal  lobe,  which,  according  to  this  hypothesis,  H 
would  have  to  be  also  a centre  of  conservation  of  images.  This 
argument  is  drawn  from  an  examination  of  aphasia,  and  further  on'i 
we  shall  go  into  it  more  fully.  By  this  path,  again,  we  should  come  | 
to  deny  that  the  sensory  centres  are  centres  for  the  formation  and  ' 
conservation  of  images.  For  the  present  it  is  sufficient  to  remember  ; 
that  the  so-called  parrot  speech  (echologos)  will  overthrow  all,] 
such  arguments.  I 

In  this  form  of  dysphasia,  due  to  interruption  of  the  logo -sensory 
paths  and  the  centres  of  intelligence,  the  words  spoken  by  others^’ 
are  not  understood,  because  the  correlative  nervous  waves  do  noti' 
reach  the  field  of  intellect.  All  the  same,  the  patient  repeats  the  : 
words  as  a parrot  does,  and  this  is  proof  of  the  evocation  of  the  cor- 
responding image  pre-existing  in  the  acoustic  sensory  centre,  of  its 
passage  to  the  motor  centre,  and  of  the  evocation  in  loco  of  the  ' 
tactile-motor  image  without  the  intervention  of  the  apperceptive  ; 
centre. 

Those  who  maintain  that  the  frontal  lobes  are  the  organs  of  | 
evocation  deduce  another  argument  in  favour  of  their  doctrine  from  ' 
the  painful  sensation  of  effort,  amounting  to  actual  plan,  that  we  j 
are  conscious  of  in  the  frontal  region  when  we  endeavour  to  reproduce  i 
something  that  we  are  sure  we  once  knew,  but  cannot  recollect  at  | 


PHYSIO-PATHOLOGY  OF  MEMORY 


255 


the  moment.  This  feeling  of  pain  in  the  frontal  lobes  ma\^  well 
be  the  organic  resonance  of  the  work  of  the  supreme  regulative  organ 
— excitant  and  inhibitive — which  comes  into  play  in  the  process  of 
voluntary  evocation,  in  which  the  whole  psychic  personality  takes 
part,  especially  in  the  development  of  abstract  concepts  ; but  it 
does  not  authorize  the  conclusion  that  there  exist  in  those  lobes  the 
centres  of  the  formation  and  conservation  of  images,  because,  as 
we  have  just  seen,  evocation  is  subsequent  to  association,  and  is 
not  the  exclusive  property  of  the  frontal  lobe,  but  is  regulated  by 
the  same  laws  as  regulate  association. 

Reproduction  succeeds  evocation,  but  sometimes  arises  inde- 
pendently of  it.  Herbart  had  already  insisted  strongly  on  the 
tendency  of  ideas  to  reappear  (Vorstellungsthdtigkeit).  This  thesis 
has  been  subjected  to  examination  and  to  experim,ental  proofs,  by 
which  it  has  been  confirmed,  thanks  to  the  observations  and  re- 
searches of  Ebbinghaus,  Mueller  and  Schumann,  Jacobs  and  Munster- 
berg,  Paneth,  Baldwin,  Bolton,  Kirkpatrick,  Binet  and  Henry 
Jastrow,  Scripture,  and  many  others.  From  all  these  studies  there 
stands  out  clearly  the  fact  that,  if  the  copy  of  things  as  ideas  in 
memory  is  the  only  mode  of  conceiving  mem,ory,  yet,  inasmuch  as 
it  is  much  weaker  with  respect  to  actual  sensations,  it  is  impossible 
to  pass  over  a number  of  subsidiary  elements  that  concur  in  the 
reproduction,  coming  from  all  the  mental  phenomena  associated 
with  sensation. 

These  last  accompany  the  reproduction,  according  to  the  same 
law  as  regulates  the  fixation  of  the  psychic  processes  that  are 
associated  with  a sensation,  or  provoked  by  it  in  the  fields  of  in- 
tellect, emotion,  and  movement.  The  number  and  the  force  of  the 
associated  phenomena  vary  according  to  the  nature  of  the  sensations 
and  their  associative  power.  Here  we  behold  clearly  the  same 
fundamental  law  of  association  in  the  mechanism  of  memory  as  in 
that  of  perception. 

We  have,  therefore,  to  consider  two  modes  of  reproduction — the 
one  that  follows  upon  voluntary  or  involuntary  evocation,  and  the 
spontaneous  mode,  not  provoked  by  any  representation  in  con- 
sciousness, but  by  the  sum  of  all  those  internal  stimuli  and  of  psychic 
facts  of  unconsciousness,  that  accompany  the  apparently  autoch- 
thonous reappearance  of  an  image  that  surprises  the  consciousness. 

As  we  have  already  observed,  it  may  be  agreed  that  the  seat  of 
reproduction  does  not  coincide  with  that  of  evocation.  Evocation 
is  always  performed  by  another  psychic  component  belonging  to 
some  one  of  the  hierarchic  grades  of  which  the  mind  is  constituted  ; 
but  reproduction  can  take  place'  only  in  the  actual  centre  of  for- 
mation and  of  conservation  of  the  percepts  and  their  derivatives. 
Evocation  is  the  process  by  which  a psycho-nervous  wave  reaches 
the  centre  of  conservation  and  excites  the  reproduction.  The 


PSYCHIATRY 


256 

centre  of  the  latter  must  be  in  a state  of  excitability — that  is  to  say, 
must  possess  a potential  that  permits  of  the  reproduction  and  the 
representation  of  the  percepts.  Hallucinations  and  some  dreams 
are  reproductions  that  occasionally  have  not  been  evoked  ; just  as 
we  may  have  evocation  without  reproduction,  on  which  matter 
we  have  already  said  sufficient. 

Recognition  is,  in  the  opinion  of  some,  another  moment  of  the 
mnesic  process.  By  it,  when  we  perceive  an  object,  a person,  or 
a place  that  has  previously  fallen  under  our  senses,  or  when  we 
represent  to  ourselves  a thought  that  had  already  been  formed,  we 
judge  that  these  are  already  known  to  us,  and  were  at  a former  time 
the  object  of  our  perceptive  or  formative  effort. 

The  power  of  recognition  has  been  subjected  to  experimental 
study  by  Binet  and  Henry,  and  by  Bourdon  (‘  Observation  com- 
parative sur  la  Reconnaissance'  Revue  Philosophique,  1895). 
Bourdon  pronounced  within  the  hearing  of  the  subject  of  the  ex- 
periment a series  of  letters  and  words  at  the  rate  of  one  letter  or  one 
word  every  second  or  every  half  second,  taking  care  to  place  the  same 
letter  or  word  twice  in  the  series.  In  this  way  he  managed  to 
determine  the  interval  between  the  two  words  or  letters  that  is 
most  suitable  for  the  process  of  recognition.  Thus,  for  example,  in  ■ 
a series  of  eighteen  words  the  interval  at  which  fewest  errors  in  ; 
recognition  are  made,  is  nine  words— that  is  to  say,  that  recognition  : 
is  easiest  when  the  same  word  occupies  the  fifth  and  fourteenth  ' 

places.  ^ < 

According  to  Bourdon,  in  recognition  there  is  a more  facile  and  ' 
more  rapid  perception,  accompanied  by  a sentiment  that  is  intel- 
lectual in  origin.  This  is  in  great  measure  in  agreement  with  the 
hypothesis  of  Lehmann  and  Holding,  who  think  that  recognition  ■ 
is  conceivable  only  through  associated  reproduction,  which  embraces  ; 
the  motor  phenomena  associated  with  attention  (Holding),  the  | 
feelings  of  pleasure  or  pain  that  accompany  the  perception  (Kiilpe)  i 
and  the  corresponding  words  (Binet).  \ 

Recognition  and  reproduction  must  not  be  confused  with  re-  } 
vivification,  although  it  is  easy  to  see  that  the  three  phenomena 
are  of  the  same  nature.  Recognition  and  reproduction  are  pre- 
dominantly objective,  whilst  in  revivification  the  subjective  element 
assumes  great  importance.  In  the  process  of  revivification  the 
subject  is  transported,  and  is  surrounded  by  the  same  psycho- 
organic  conditions  as  on  a former  occasion  when  something  happened 
that  had  a great  interest  for  his  personality.  Every  accompaniment 
revives  around  him,  and  he  is  present  at  the  old  scene,  reproduced 
in  the  same  objective  and  subjective  conditions.  Here  we  have  a 
more  complex  reproduction,  which,  differing  from  simple  repro-^ 
duction,  is  the  result  of  the  labour  of  the  whole  of  the  brain,  and  isr 


PHYSIO-PATHOLOGY  OF  MEMORY 


257 


associated  with  very  strong  emotional  states,  which  in  their  intensity 
are  very  similar  to  those  accompanying  the  actual  scene  or  the  real 
event,  although  they  be  the  production  of  fancy. 

We  now  come  to  examine  the  question  whether  evocation  and 
reproduction  are  phenomena  so  bound  up  with  consciousness 
that  consciousness  is  one  of  their  necessary  conditions,  or  whether 
the  mnesic  process  may  come  into  play  independently  of  conscious- 
ness, when  consciousness  would  have  to  be  considered  only  as  an 
accessory  condition.  Consciousness  is  not  a substantial  fact  of  the 
mnesic  process,  as  we  shall  see  in  a subsequent  chapter  ; it  is  a 
phenomenon,  one  of  the  forms  of  activity  of  the  nervous  system, 
and  therefore  it  is  not  indispensable  to  the  process  of  thought, 
which  is  conditioned  for  the  formiation  and  reproduction  of  ideas, 
relations,  etc.,  through  the  associative  links  that  establish  relations 
between  the  various  factors  of  thought,  acting  quite  independently 
of  consciousness. 

The  mechanism  of  memory  is  unconscious  ; nevertheless,  we 
distinguish  a conscious  memory  and  an  unconscious,  or,  to  express 
ourselves  with  greater  precision  of  language,  a conscious  and  an 
unconscious  side  of  the  mnesic  process. 

In  the  sarnie  way  as  organic  relations  are  established  in  the  pro- 
gress of  the  perceptive  process,  according  to  the  laws  of  association, 
with  or  without  consciousness,  given  the  action  of  stimuli  operating 
upon  the  nervous  system,  in  an  equal  degree  there  are  reproduced 
the  same  facts,  the  same  miodihcations  that  the  nervous  system 
once  underwent,  through  the  influence  of  the  same  or  analogous 
stimmli  or  their  psychic  derivatives,  independently  of  consciousness. 

That  the  phenomenon  of  miemiory  is  not  necessarily  conscious 
everyone  miay  judge  for  himiself  from  a number  of  facts  within  his 
own  experience. 

Names  or  other  words,  for  example,  that  sometimes  we  cannot 
recall  at  will,  come  into  consciousness  when  we  are  actually  thinking 
no  more  about  them,.  Events  of  a long-distant  past  break  into  con- 
sciousness and  interrupt  the  course  of  another  order  of  ideas,  or  they 
reappear  in  dreams. 

Certain  sensations  and  certain  movements  m,ay  have  been  con- 
scious for  a certain  time,  but  they  become  unconscious  through 
repetition,  and  are  perfected  through  fixed  relations  of  the  organic 
mechanism.  For  example,  the  art  of  walking  was  once  conscious, 
when  the  child  had  to  learn  the  various  movements  with  great  effort, 
and  to  co-ordinate  them  duly,  so  as  to  maintain  its  equilibrium,. 
Later,  through  long  repetition  of  the  corresponding  states  of  con- 
sciousness, the  m,echanism  was  gradually  driven  out  of  consciousness, 
so  that  in  the  adult  it  acts  independently  of  consciousness  (auto- 
matism,). 

When  walking  has  already  become  an  automatic  process — that  is 
to  say,  when  the  organic  m,emory  has  substituted  itself  for  a m.em.ory 

17 


258 


PSYCHIATRY 


of  consciousness  and  volition — there  is  no  further  volitional  element 
in  it  than  the  objective  towards  which  it  is  directed.  How  much 
volition  is  there  in  the  speech  of  an  individual  ? What  does  he 
know  beforehand  of  all  the  words  that  must  succeed  one  another  in 
the  expression  of  a given  thought,  when  at  a given  moment 
of  time  there  can  remain  in  the  visual  field  of  consciousness  only 
a very  limited  number  of  representations  ? Certainly  we  fix  the 
abstract  concept  that  we  wish  to  develop,  the  synthesis,  often  in- 
cluded in  a single  word  ; but  ideas  and  words  follow  one  upon  another 
by  force  of  association  between  the  multiple  elements  from  which 
the  abstract  concept  has  been  gradually  formed.  The  same  may 
be  said  of  the  writer,  the  pianist,  and  so  on. 

It  sometimes  occurs  that  certain  phenomena  do  not  reach  the 
visual  field  of  consciousness,  and  yet  they  may  be  produced  inde- 
pendently of  the  will  and  in  certain  particular  states.  So,  even  when 
certain  things  be  not  learned  because  the  learner  does  not  pay 
due  attention,  they  may  be  reproduced  under  special  conditions. 
Mnemonic  reproduction  is  therefore  neither  strictly  bound  up  with 
apperception  nor  with  voluntary  registration. 

In  some  phases  of  hysteria,  in  hypnotism,  in  dreams,  under  the 
influence  of  powerful  stimulants  of  the  cerebral  mantle,  or  in  some 
other  form  of  morbid  hyperactivity  of  the  brain — mania,  etc. — 
we  may  represent  to  ourselves  objects,  persons,  places,  verse,  and 
prose,  thoughts  known  or  formed,  all  of  them  buried  in  the  ocean 
of  oblivion,  from  whose  depths  no  power  of  volition  could  ever  have 
drawn  them  to  the  surface.  It  is  superfluous,  therefore,  to  admit 
that,  with  or  without  volition,  the  nervous  system  receives,  con- 
serves, and  reproduces,  and  that  in  the  process  of  memory,  as  in  the 
greater  number  of  mental  phenomena,  consciousness  has  only  the 
duty  of  imprinting  its  particular  character. 

We  may  formulate  the  general  laws  that  govern  the  mnemonic 
function.  One  of  these  is  as  follows  : 

An  impression  is  so  much  the  better  retained,  and  therefore  the 
analogous  modification  of  the  nervous  system  is  so  much  more 
easily  reproducible,  the  more  intensely  the  impression  has  acted. 
The  strongest  states  of  consciousness  are  those  that  pass  most 
forcibly  over  its  field,  and  these  are  more  easily  represented  ; whilst 
the  weaker  states  remain  latent  and  are  reproducible  only  in  states 
of  superexcitation. 

The  same  effect  is  observed  when  attention  is  strongly  concen- 
trated on  the  most  powerful  elements  of  association,  with  reference 
to  time  and  space,  in  which  case  all  the  other  less  highly  coloured 
images  that  have  various  bonds  of  association  with  these,  including 
more  especially  those  of  time  and  space,  gradually  reach  the  field 
of  conscious  memory.  Those  very  strong  impressions  we  call 
points  of  rendezvous — a happy  phrase  introduced  by  Ribot — 
and  they  are  just  the  ones  that  have  most  intensely  stimulated 


j 

I 

i 

\ 


PHYSIO-PaTHOLOGY  of  memory  259 

the  nervous  system,  those  in  which  the  ego  has  participated  most 
strongly. 

At  various  periods  in  life,  and  especially  in  childhood  and  youth, 
events  happen  and  sensations  succeed  one  another,  leaving  very 
strong  impressions  at  a determined  moment  in  the  period  of  the 
formation  of  the  personality — strong,  perhaps,  because  they  are  new  ; 
these  impressions  are  what  the  adult  man  principally  and  most 
frequently  represents  to  himself. 

The  memory  of  those  facts  appears  always  to  dwell  on  the 
threshold  of  consciousness,  ready  for  representation,  and  such  im- 
pressions have  the  strongest  power  of  invasion  of  consciousness. 
In  the  revolution  of  the  psychic  constellation  these  impressions, 
with  their  accelerated  motion,  tend  always  to  enter  into  conscious- 
ness, whilst  to  represent  less  vivid  memories  an  effort  of  volition  is 
required,  and  also  a search  for  points  of  rendezvous  that  will  enable 
us  to  re-evoke  all  those  other  images  that  cannot  for  the  moment  be 
called  to  memory. 

Every  person  may  prove  this  truth  for  himself  by  the  intro- 
spective method  of  psychology. 

Of  all  the  events  that  happen  in  our  daily  life,  the  one  most 
easily  represented  is  that  which  has  caused  our  minds  to  vibrate 
most  strongly.  Emotion  and  interest  of  the  ego  in  the  impressions 
are  the  conditions  of  a ready  and  certain  evocation.  This  fact  is 
bound  up  with  the  law  of  the  intensity  of  the  stimulus. 

How  often  does  it  happen  that  we  cannot  recall  a name,  or  that 
instead  of  the  name  we  remember  only  the  sound  of  it,  or  the  sound 
of  its  accented  syllable  ! For  example,  in  the  words  Michele, 
Antonia,  Arnaldo  the  accented  sounds  are  respectively  e in  che, 
0 in  to,  and  a in  nal.  Now,  it  is  frequently  the  case  that  the  funda- 
mental sound  is  remembered,  while  the  whole  word  is  not,  and  I 
think  for  the  reason  that  the  accented  sound  has  made  a stronger, 
and  therefore  less  unstable  impression,  whilst  the  whole  word, 
which  is  a more  complex  and  therefore  more  unstable  composition, 
fades  from  mem.ory  more  easily.  Thus  the  sound  of  the  accented 
syllable  very  often  becomes  the  rendezvous  for  the  word,  through 
which  we  recollect  all  the  other  parts  that  go  to  make  it  up. 

Not  all  men  present  the  same  mnesic  disposition  for  the  various 
forms  of  images.  There  is  a notable  difference  among  men,  and 
this  is  certainly  one  of  the  most  substantial  reasons  of  differences 
in  intellect  and  in  conduct. 

As  will  easily  be  understood,  three  main  orders  of  images  enter 
into  the  constitution  of  thought — the  tactile-motor,  the  visual,  the 
aural ; and  even  when  we  consider  the  higher  mental  products, 
such  as  words,  we  find  that  these  are  formed  of  the  same  orders  of 
images  (see  Part  I.,  p.  135,  et  seq.). 

Owing  to  the  very  different  circumstances  under  which  the 
lives  of  individuals  are  developed,  and  especially  for  reasons  of 

17 — 2 


26o 


PSYCHIATRY 


heredity  (Ribot),  the  various  parts  of  the  brain  are  not  all  developed 
proportionately,  and  the  inequalities  in  their  evolution  cause 
inequalities  in  function,  which  are  expressed  in  the  readier  formation 
of  images  and  in  the  more  certain  and  durable  conservation  of  these, 
likewise  in  their  readier  reproduction,  with  miore  colouring,  in  those 
parts  of  the  cerebral  m,antle  that  are  miost  evolved.  In  this  way 
mnesic  types  are  formed  am.ong  men,  who,  for  this  reason,  must 
have  diverse  inclinations,  tendencies,  emmtions,  and  aptitudes 
according  as  there  is  predominance  of  visual,  aural,  or  tactile 
images  in  the  comiplex  formation  of  the  mind.  From  the  point  of 
view  of  m.emory  we  can  thus  classify  mien  as  motor,  visual,  and  aural. 

We  do  not  stop  to  consider  the  division  into  conceptual  and 
sensorial,  because,  as  will  be  pointed  out  in  the  next  chapter,  the 
conceptual  exist  only  through  the  representation  of  the  words  that 
synthetize  the  concepts,  and  therefore  we  find  ourselves  again  in  a 
sensory  field,  except  that  here  the  content  is  of  words.  Conceptual 
men  m.ay  also  be  divided  into  motor,  visual,  and  aural,  according 
as  kinaesthetic,  visual,  or  aural  word-images  prevail,  and  there- 
fore are  represented  in  the  formiation  of  words.* 

* This  classification  of  men  according  to  their  mnesic  qualities  is  very 
rough  indeed.  Individual  varieties  are  innumerable,  and  depend  upon 
age,  sex,  race,  and  the  different  mental  development  of  individuals.  In 
this  regard  the  investigation  made  by  W.  Colegrowe  (‘  Individual  Memories,’ 
Amer.  Journ.  of  Psychol.,  1898-1899)  is  of  very  great  value.  He  deals  with 
1,658  replies  to  the  same  list  of  questions  sent  to  different  persons, 
who  in  turn  made  an  examination  of  themselves  and  of  persons  of  their 
acquaintance,  including  infants.  With  regard  to  age,  the  investigation 
includes  groups  of  individuals  aged  i to  4,  5 to  9,  10  to  ii,  12  to  13,  and  so 
on  up  to  20  years.  From  20  upwards  the  groups  go  by  decades — 20  to  29, 
30  to  39,  and  so  on  up  to  90  years.  The  memory  in  different  individuals 
develops  in  a very  different  measure  at  successive  ages.  It  is  important 
to  note  that  memory  attains  its  highest  power  in  the  decade  from  20  to  29. 
and  is  maintained  at  that  level,  with  some  diversity  of  character,  in  the 
succeeding  decade,  30  to  39.  In  this  last  decade  logical,  intellectual,  and 
topographical  memory  reaches  its  maximum  both  in  men  and  in  women,  and 
this  holds  also  of  memory  for  numbers  and  for  time.  In  the  next  decade, 
40  to  49,  memory  for  persons  begins  to  fail.  In  this  investigation  there  is 
much  that  is  of  very  great  value  for  teachers,  who  might  draw  largely  from 
it  in  their  studies  of  mnemo-technical  processes,  and  the  heedless  and  ignorant 
compilers  of  the  schemes  of  study  in  our  schools  would  also  gain  by  reading 
this  report.  In  these  investigations  and  in  many  others  they  would  find 
convincing  proof  that  it  is  impossible  to  present  the  same  thing  under  a new 
form,  as  is  done,  without  any  method,  in  grammar,  geography,  and  history, 
without  confusing  the  mind  and  weakening  the  most  important  of  mental 
energies — that  is,  the  memory.  There  we  may  find  a rich  fountain  of  know- 
ledge to  enable  us  to  apply  the  law  of  selection  logically  in  our  schools.  Thus, 
for  example,  we  very  often  find  a memory  that  is  retentive  of  history  and 
literature  conjoined  with  incapacity  for  original  thought,  and  a notable 
weakness  for  mathematics.  From  all  these  studies  we  learn  clearly  the  hurtful 
influence  of  distraction  on  the  process  of  memory,  and  this,  expressed  in 
common  language,  is  equivalent  to  a denunciation  of  the  very  great  harm 
that  scholastic  programmes  and,  in  a less  degree,  the  methods  followed  in 
the  greater  number  of  our  high  schools  and  academies,  do  to  the  freshness 
and  force  of  Italian  thought. 


PHYSIO-PATHOLOGY  OF  MEMORY 


261 


The  history  of  the  arts  and  sciences  gives  us  an  extraordinary 
number  of  examples  to  prove  these  facts,  which,  indeed,  are  no 
longer  contested. 

Most  painters  show  a great  prevalence  of  visual  memory,  and 
especially  great  vivacity  in  the  visual  images  of  which  they  have 
representations.  From,  Raphael  to  Rubens,  from  Morelli  to  Michetti, 
all  display  readiness  and  vivacity  of  visual  images,  easily  repro- 
duced with  high  colouring.  The  well-known  and  highly-esteemed 
Neapolitan  artist,  Alfonso  Simonetti,  whom  I had  to  treat  for  a 
serious  head  trouble  when  I was  beginning  my  career,  and  who 
recovered  after  a few  months,  surprised  me  by  offering  me  a 
canvas  with  a very  faithful  portrait  of  myself,  although  I had 
never  given  him  a sitting,  and  he  had  no  photograph  of  me. 

Musicians,  like  poets,  are  generally  aural,  and  the  dispropor- 
tionate development  of  the  cerebral  region  in  question,  and  there- 
fore of  the  aural  memory,  appears  very  early  in  life  in  many  cases. 

Mozart,  Beethoven,  Petito,  and  all  the  great  pianists  and  com- 
posers, were,  with  regard  to  their  surprising  aural  memory,  genuine 
examples  of  marvellous  physiological  hypermnesia.  Poets,  like 
orators,  are  sensible — as  if  they  heard  them — of  the  harmonies  of 
rhythm,  of  phrase,  of  sounds,  independently  of  the  ideative  content 
of  their  works  of  art. 

Bain  says  that  ‘ inclination  towards  some  subject — botany, 
zoology,  antiquities,  music — is  innate  in  us,  and  this  is  often  said 
with  reason.  The  powers  of  the  brain  must  from  the  very  beginning 
incline  us  strongly  towards  a certain  class  of  impressions,  and  to 
these  we  shall  come  to  direct  our  intensest  study.’ 

As  for  what  is  innate,  we  must  recognise  the  law  of  heredity 
(Ribot)  which  explains  how  in  whole  families  of  artists  the  same 
mnesic  phenomenon  is  repeated,  sometimes  with  marvellous  pro- 
gressiveness. It  not  infrequently  happens  that  a modest  dilettante  in 
painting  gives  us  a great  artist,  just  as  Mozart  the  father,  of  slight 
ability,  gave  us  the  great  Mozart  the  son,  and  as  Madame  Petito, 
the  dilettante  pianist,  gave  us  that  marvel  of  a son  whose  psycho- 
logical figure  has  surprised  so  many  students  of  psychology.* 

As  a rule,  the  predominant  cerebral  development  is  not  limited 
to  a single  sensory  area.  When  we  study  these  great  artists  we 
never  find  aural,  visual,  or  motor  memory  exclusively.  -Generally 
we  find  visual-motor,  as  in  sculptors  and  painters,  ‘ who  have  their 
eyes  in  their  fingers,’  or  aural-motor,  like  orators,  poets,  singers,  etc. 

I am  of  opinion  that,  in  this  regard,  there  are  no  men  with  abso- 
lute equilibrium  of  development.  In  very  few  cases  have  I been 

* Petito,  a Spanish  child,  was  mentioned  by  P.  Richet  in  the  Psycho- 
logical Congress  held  at  Paris  in  1901.  At  three  and  a half  years  this  child 
knew  by  heart  a score  of  whole  pieces  of  music,  harmony  and  melody.  At 
two  and  a half  years  he  repeated  on  the  piano,  unaided,  a musical  composition 
that  a musician  had  presented  to  his  mother,  whom  he  heard  practising  it 
on  the  piano. 


262 


PSYCHIATRY 


able  to  find  an  equal  participation  of  all  the  categories  of  images 
in  the  highest  formations  of  the  mind,  and  in  the  manifestations 
of  life  ; further,  those  with  minds  miost  nearly  balanced,  owing  to 
the  various  conditions  of  existence  and  to  their  exercising  one 
sense  miore  than  another,  end  by  having  a certain  predominance 
of  one  category  of  imiages  over  the  others.* 

Anomalies  of  miemory  are  almiost  all  by  way  of  defect,  and  they 
may  be  general  or  partial.  Anomalies  on  the  side  of  excess  are 
also  found,  but  it  is  very  difficult  to  draw  the  line  of  demarcation 
between  the  physiological  and  the  pathological  mnesic  process,  when 
the  memory  is  quick  and  faithful.  When  the  brain  is  especially 
reproductive  it  is  inferred  from  that  that  a higher  potential  of  the 
intellectual  patrimony  of  the  personality  is  available  ; that  is 
always  to  the  advantage  of  the  personality  in  its  individual  and 
social  relations.  Should  a person  speak  or  write  logically  from 
morn  to  night,  provided  his  words  be  opportune  and  to  some  purpose, 
no  one  will  argue  that  he  is  not  of  sound  mdnd  merely  on  the 
ground  that  he  has  hypermnesia. 

The  ideal  of  the  sane  man  is  the  maximum  of  efficacious  activity. 
I have  known  orators  speak,  without  interruption  or  fault,  for 
seven  hours  on  end,  always  observing  a rigorously  logical  struc- 
ture of  thought,  and  using  a very  large  vocabulary,  which  is 
wholly  based  on  memory.  Such  cerebral  activity  is  desirable  in  a 
much  greater  number  of  men  than  those  who  really  possess  it. 

Hypermnesia  per  se  is  not  a morbid  phenomenon.  It  is  the 
facts  that  accompany  hypermnesia  that  give  it  its  truly  m,orbid 
character.  The  changed  tone  of  the  personality,  superficiality  of 
attention,  errors  in  perception  and  in  judgment,  inefficacy  of  thought, 
errors  in  logic,  strange  actions,  doubling  of  personality,  as  in  some 
phases  of  hypnotism — these  are  the  concomdtant  psychic  phenomena 
which,  along  with  the  somatic  phenomena,  cause  us  to  consider 
hypermnesia  morbid. 

In  our  everyday  life  how  mmch  there  is  that  we  do  not  remem,ber  ! 
All  that  has  not  very  strongly  im,pressed  us,  that  has  not  awakened 
intense  states  of  consciousness,  we  have  great  difficulty  in  evoking 
at  will,  or  at  most  our  representation  of  it  is  pale  and  incom,plete. 
Sometim,es  it  happens  that  we  awake  in  surprise  during  a dream, 
and  at  the  mom,ent  we  have  a lively  representation  of  the  scenes 
ol  the  dream,  but  these  fade  away  gradually,  and  it  is  im,possible 
to  recall  them — they  are  drops  lost  in  the  ocean  of  oblivion.  Such 

* We  must  not  overlook  the  fact  of  the  prevalence  of  one  category  of 
images  over  others,  a characteristic  generally  inherited.  This  reveals  itself 
in  special  likings  of  children,  and  it  is  a matter  of  the  very  greatest  importance 
for  teachers,  as  it  would  be  useful  to  favour  and  cultivate  such  natural  inclina- 
tion, by  applying  the  law  of  differentiation  which  is  fundamental  for  human 
progress.  This  does  not  mean  the  neglect  of  the  education  of  the  other 
senses,  but  such  natural  inclinations  are  one  of  the  keys  of  fortune  both  for 
individuals  and  for  collective  humanity. 


PHYSIO-PATHOLOGY  OF  MEMORY 


263 


is  the  fate  of  an  indefinite  number  of  impressions.  ‘ In  the  practical 
use  of  our  intellect,’  says  James,  reproducing  almost  verbally  the 
thought  of  Ebbinghaus,  ‘ forgetting  is  as  important  a function 
as  remembering.’  Locke  says,  ‘ Our  minds  represent  to  us  those 
tombs  that  we  are  fast  approaching  ; where,  though  the  brass  and 
marble  remain,  yet  the  inscriptions  are  effaced  by  time,  and  the 
imagery  moulds  away.’ 

Under  some  special  conditions,  however,  certain  records  of  real 
impressions  and  of  positions  beheld  in  dreams  recover  their  colouring, 
and  are  revived.  Under  the  action  of  certain  stimulants,  like  tea, 
coffee,  or  alcohol,  when  the  tone  of  the  brain  is  exalted,  when  the 
circulation  of  the  arterial  blood  is  accelerated,  we  can  remember 
many  things  that  never  recur  to  the  mind  in  our  ordinary  state. 
In  mania  the  memory  is  exalted.  Individuals  originally  sober  in 
speech  talk  a great  deal  under  maniacal  excitement,  speaking  of 
many  things  that  had  never  form,ed  the  theme  of  thought  or  dis- 
course in  their  norm.al  state.  An  unwonted  num,ber  of  recollec- 
tions are  recalled  from  the  depths  of  m^emmry,  either  by  other 
images  or  by  the  most  insignificant  actual  stimmli.  It  would  seem 
that  a vivifying  wave  traverses  that  great  world  of  living  entities 
in  a state  of  lethargy — the  world  of  oblivion. 

The  memory  m,ay  be  exalted  in  hysteria  and  in  natural  or  induced 
somnambulism,  and  in  the  past  such  exaltation  has  led  people  to 
accept  as  miracles  facts  that  have  since  been  demonstrated  to  be 
phenomena  of  nervous  physio-pathology.  A young  woman  fell 
into  a state  of  somnambulism.  Years  before,  when  in  her  bedroom, 
she  had  overheard  her  uncle  recite  certain  psalms  that  he  was 
reading  in  his  Bible,  and  although  she  did  not  understand  what  he 
was  saying,  not  having  education  enough  to  follow  or  to  fix  the 
lines  in  her  m,em,ory,  yet  in  her  somnambulism  she  could  repeat 
these  psalms  that  had  not  m,ade  either  strong  or  conscious  impres- 
sions on  her  nervous  system. 

History  tells  of  certain  epidemic  forms  of  hysteria,  such  as  the 
chorea  major,  the  victims  of  which  set  forth  on  pilgrimages  to  various 
shrines,  leaping  and  dancing,  singing  hymns  that  they  had  never 
learned,  and  speaking  tongues  they  had  never  studied. 

Facts  of  ancient  date,  that  seemed  to  have  disappeared  for  ever 
from  the  world  of  memory,  come  to  life  again  during  the  excite- 
ment of  fever,  in  the  delirium  of  intoxication,  or  at  the  beginning 
of  slight  meningitis. 

Cases  are  not  infrequent  in  which  individuals,  mostly  unedu- 
cated, begin  to  speak  in  some  strange  language  that  they  do  not 
know,  to  the  great  astonishment  both  of  the  bystanders  and  the 
speakers  themselves. 

Som,e  hysterical  subjects  can  also  write  pieces  of  prose  and  verse 
of  which  they  had  no  notion  in  the  sane  state.  Richet  says  of 
somnambulists  that  they  rem,ember  places,  persons,  and  events 


264 


PSYCHIATRY 


with  an  incredible  degree  of  exactitude.  A hysterical  subject  was 
able  to  sing  the  second  act  of  ‘ Africana  ’ when  he  was  in  a hypnotic 
sleep,  but  could  not  remember  a single  note  when  awake.  Another, 
who  when  awake  could  not  remember  a quotation  from  a book, 
however  hard  he  tried,  rem.embered  the  whole  passage,  the  volume, 
the  page,  and  the  paragraph  when  he  was  in  a hypnotic  sleep  (Moury). 
Examples  might  be  multiplied.  I myself  dreamed  one  night  and 
repeated  with  the  utmost  clearness  som,e  Russian  words  from  an 
article  by  Kowalewski  which  I had  seen,  but  not  understood,  for  I 
do  not  know  Russian.  These  words  I had  so  clearly  before  m.e 
when  I awoke,  and  for  a few  moments  after,  that  I was  very  much 
surprised,  and  for  a time  pleased  myself  with  the  thought  that  I 
possessed  a very  superior  faculty,  a newly-acquired  power  ; but, 
half  an  hour  later,  I had  completely  forgotten  the  words,  and  I 
have  never  since  been  able  to  re-present  them,  although  for  the 
moment  they  appeared  so  familiar  to  me. 

In  such  cases  imagination  creates  nothing  new  : it  only  effects 
the  reproduction  of  what  was  once  registered  by  the  nervous  system, 
but  cannot  be  reproduced  at  will. 

We  have,  therefore,  an  anomaly  of  memory  on  the  side  of 
excess,  which  would  not  constitute  a pathological  fact  if  it  were  not 
that  it  represents  one  of  the  factors  of  a morbid  whole  that  is  mmch 
more  complex  and  various.  In  the  maniac  it  is  one  of  the  . 
phenomena  of  the  great  excitability  of  the  whole  brain  ; in  som,-  , 
nambulism  it  is  exalted  at  the  expense  of  perception,  of  attention,  ; 
of  judgment,  and  of  will  ; in  hysteria  it  may  be  at  most  one  of  the  ! 
most  brilliant  pictures  of  the  morbid  kaleidoscope  and  nothing 
more.  • | 

Hypermnesia  of  this  sort  reflects  the  evocative  and  reproductive  ■ 
power,  and  is  to  be  referred  as  much  to  the  facts  perceived  or  thought  ; 
of,  and  then  forgotten,  as  to  those  conserved,  so  to  speak,  uncon-  - 
sciously,  of  which  the  subjects  appear  not  to  know  even  that  they  ? 
form  part  of  their  experience  (Guillon,  Essai  sur  les  HyPermnesies,  ^ 
Paris,  1897).  " I 

Exaltation  of  memory  may  be  partial.  This  has  its  counter-  j 
part  in  physiological  life,  but  the  phenomenon  is  truly  morbid  in  j 
some  cases  of  defective  development  of  the  nervous  system.  As 
we  have  observed  previously,  there  are  individuals  who,  owing  to 
their  organic  constitution  or  their  habits,  can  reproduce  certain 
images  much  better  than  others. 

The  phenomenon  is  really  pathological,  and  is  ot  no  little  impor- 
tance in  certain  cases  of  defective  cerebral  development.  With 
imbeciles,  in  whom  such  functional  asymmetry  is  frequent,  cor- 
lesponding  of  necessity  to  anatomical  asymmetry  that  results  from 
greater  development  of  one  part  of  the  brain  than  of  the  others, 
partial  memorj^  of  one  order  of  images  is  very  strong.  Such  a fact 
should  not  surprise  us,  and  it  is  not  even  exceptional,  when  we 

i 

i 


PHYSIO-PATHOLOGY  OF  MEMORY 


265 


consider  that  many  artists,  men  of  letters,  scientists,  etc.,  who  are 
hypermnesic  for  many  things,  prove  themselves  amnesic  imbeciles 
as  regards  other  things  that  are  quite  ordinary  and  even  essential 
in  life. 

There  are  imbeciles  who  can  read  a page  of  print  without  under- 
standing it,  and  repeat  what  they  have  read,  word  for  word  (Ireland, 
Drobisch  reported  by  Ebbinghaus,  Sollier). 

The  memory  of  weak-minded  persons,  even  when  it  is  highly 
developed,  is  of  no  service.  It  rests  upon  associations  of  contiguity, 
and  therefore  imbeciles  are  incapable  of  detaching  the  parts  of 
which  a representation  is  constituted  from  their  ordinary  relations. 
‘ Imbeciles,’  writes  Sollier,  ‘ always  repeat  things  in  the  order  in 
which  they  have  learned  them.  ...  If,  for  example,  they  have 
learned  the  days  of  the  week  commencing  with  Thursday,  and 
they  are  asked  to  repeat  them  beginning  with  Monday,  they  cannot 
do  it.’ 

Such  a state  of  affairs  has  its  counterpart  in  certain  indi- 
viduals who  are  well  evolved.  I know  some  persons,  even  highly- 
gifted  persons,  who  resemble  Dr.  Leyden,  mentioned  by  Ribot. 
Leyden  could  repeat  a long  Act  of  Parliament  after  a single  reading, 
but  when  he  wished  to  recall  some  particular  point  in  what  he  had 
read,  he  could  do  it  only  by  repeating  from  memory  the  whole 
passage,  from  the  very  beginning  down  to  the  point  that  he  wished 
to  recall. 

Other  imbeciles  have  a very  highly  developed  memory  for 
numbers.  Some  can  work  a multiplication  or  a division  by  several 
figures  mentally,  giving  the  product  or  the  quotient  correctly  and 
rapidly  (cases  of  Ireland,  Zuccarelli,  and  others).  These  examples 
among  phrenasthenics,  even  of  an  extreme  degree  of  weakness,  find 
a counterpart  in  those  great  arithmetical  and  mathematical  geniuses 
of  whom  we  have  already  spoken,  such  as  Henry  Mondeux,  Rinaudi, 
Diamandi.  The  report  presented  to  the  French  Academy  about 
Henry  Mondeux,  said  that  he  required  only  five  minutes  to  learn 
and  keep  in  mind  a number  of  twenty-four  figures,  while  he  had  the 
greatest  difficulty  in  remembering  the  names  of  persons,  places, 
and  things. 

Binet  says  of  Rinaudi  that  his  forgetfulness  of  matters  relating 
to  ordinary  life  is  in  glaring  contrast  to  his  enormous  memory  for 
figures,  which  is  about  a hundred  times  greater  than  the  average 
in  normal  men.  He  could  repeat  thirty-six  figures  without  a mistake 
in  the  same  order  as  he  read  them. 

Others  show  true  hypermnesia  for  tactile  images  (tactile  hyper- 
mnesia). 

Some  imbeciles  or  idiots  repeat  passages  of  music  perfectly,* 

* Sollier,  Ireland,  Wildermuth,  Bernardini,  and  Ferrari  have  made  a 
study  of  the  memory  for  music  in  phrenasthenics.  In  one  hundred  such 
subjects,  the  two  last  authors  found  twelve  with  highly  developed  sensibility 


266 


PSYCHIATRY 


or  they  can  reproduce,  more  or  less  accurately,  mechanical  con- 
trivances that  they  have  seen  but  once.  Griesinger  speaks  of  an  [■ 
imbecile  who  could  with  comparative  exactitude  make  a m.odel  of 
a ship,  com,plete  in  all  details,  after  he  had  seen  it  by  the  seashore. 

We  must  also  note  verbal  hypermnesia  of  certain  given  things 
and  of  nam,es  of  a fixed  order.  A patient  in  the  asylum,  at  Naples 
rem,embers  the  nam,es  of  the  saints  mentioned  in  the  calendar  for 
every  day  of  the  year.  Ask  him.  to  what  saint  any  day  of  the 
month  is  dedicated  and  he  will  not  fail  to  give  a correct  and  ready 
answer.  In  all  these  cases,  however,  the  phenom,enon  has  a patho- 
logical value,  in  so  far  as  it  is  in  contrast  with  the  great  mental 
poverty  of  the  subject. 

Sometimes  hypermnesia  is  partial,  applying  only  to  single  facts, 
to  the  revivification  of  events  forgotten  for  many,  many  years,  or 
that  happened  in  infancy  or  childhood.  The  scene  from  ‘ Mignon  ’ 
is  reproduced  in  some  cases  collected  by  Guillon.  Here  is  one  of 
them  : In  the  year  1793  a mother  and  her  child,  aged  six  years, 
were  conveyed  in  a waggon  to  one  of  the  great  squares  of  the  city 
of  Orleans,  there  to  be  executed  ; but  whilst  they  were  awaiting 
their  turn,  a priest  induced  them  to  make  their  escape.  The  child 
remembered  nothing  either  of  the  city  or  of  the  particular  occurrence 
except  as  a distant  dream,.  At  the  age  of  thirty-one  she  chanced . 
to  go  to  live  at  Orleans,  and  one  day,  as  she  turned  out  of  a street , 
on  to  the  Place  Martroy,  she  suddenly  beheld  again  the  whole  of; 
that  terrible  scene — the  sam,e  square  crowded  with  people,  the  fatal; 
platform,  at  the  end,  the  waggon  on  which  her  m,other  was  lying, 
and  praying.  She  swooned  away  owing  to  the  terror  produced  by? 
the  vision. 

Defects  of  memory  are  total  or  partial.  The  form,er  m,ay  be 
temporary  or  progressive.  There  are  cases  in  which  an  individuaP 
affected  by  a given  mialady  forgets  all  that  has  happened  to  him,| 
during  a period  of  his  life,  which  m,ay  be  very  short  or  very  long,| 
hours,  days,  or  weeks.  This  blank  in  consciousness  is,  as  a rule,^ 
never  filled  up.  I 

Epileptics  remember  nothing  of  what  has  happened  to  them,  or 
what  they  have  thought  or  done,  not  only  during  the  convulsive 
attack,  but  in  some  cases  also  during  a period  preceding  the  con- 
vulsion and  another  period  following  it  ; and  if  a psychic  attack 
has  taken  the  place  of  the  convulsion  this  ammesia  continues  for  a 
time  after  the  attack  is  over.  This  phenomienon  is  alm,ost  character- 
istic of  epilepsy.  I say  ‘ almost  ’ advisedly,  because  it  must  not 
be  considered  as  a constant  fact,  since  Tamburini  and  others  have 

and  memory  for  music  ; twenty  more  understood  music,  and  could  repeat  a 
musical  phrase,  but  soon  forgot  it  ; sixteen  could  hardly  repeat  a note  or 
the  rhythm  of  the  passage.  In  the  remaining  cases  no  results  were  obtained, 
owing  to  the  bad  disposition  of  the  subjects  or  their  incapability  of  attention. 


PHYSIO-PATHOLOGY  OF  MEMORY 


267 


recorded  authentic  cases  of  epilepsy  in  which  the  memory  of  many 
things  was  preserved.  The  epileptic,  like  the  person  who  has 
suffered  from  shock  following  a serious  injury  to  the  head,  often 
finds  it  difficult  or  impossible  to  connect  the  present  with  the 
norm.al  period  preceding  the  attack  or  the  injury  (amnesia 
retrograda). 

A few  years  ago  a Major  of  the  Bersaglieri  rose  one  mmrning 
as  usual,  made  his  toilet,  gave  his  attendant  orders  to  saddle  his 
horse,  arranged  a few  other  matters,  then  went  to  the  stable  and 
mounted. 

After  going  a certain  distance  the  horse  shied,  reared  and 
became  so  excited  that  the  unfortunate  Major  was  thrown  from,  the 
saddle,  striking  his  head  against  a stone.  He  was  picked  up,  but 
remained  unconscious  for  more  than  a day.  After  his  recovery, 
which  was  very  slow,  he  was  unable  to  remember  anything  that 
had  happened  on  the  morning  of  his  serious  accident,  although  fully 
restored  to  health. 

He  remembered  the  whole  of  the  day  preceding  his  accident,  and 
everything  that  had  occurred  right  up  to  the  hour  when,  as  usual, 
he  went  to  bed.  He  could  not  rem^ember  rising  in  the  morning, 
giving  the  order  to  saddle  his  horse,  mounting  the  horse,  or  even 
any  of  his  emotions  just  before  being  thrown. 

One  August  evening,  a Roman  lady,  who  had  gone  to  Rom.e 
on  business  in  the  morning,  was  returning  in  an  auto-car  to 
Porto  d’Anzio,  where  her  husband  was  awaiting  her.  She  was 
alone  with  the  driver,  who,  as  night  was  coming  on,  went  at  a high 
speed.  At  a turn  of  the  road  they  came  upon  a waggon  drawn 
across  the  way,  causing  the  driver  to  stop  very  suddenly  and  reverse 
the  motor.  Consequently  the  auto-car  plunged  and  overturned, 
and  the  lady  was  thrown  out,  striking  the  ground  with  her  head. 
A little  later  she  was  picked  up  in  a state  of  com_plete  unconscious- 
ness and  carried  to  a hospital  in  Rome.  She  gradually  recovered 
consciousness,  was  medically  attended,  and  taken  hom,e. 

When  she  came  to  herself  she  was  conscious  of  her  surroundings 
and  of  the  men  and  objects  in  the  hospital  ; she  spoke  with  the 
doctors.  On  reaching  home  she  recognised  the  persons  belonging 
to  her  family,  and  addressed  them  in  appropriate  words.  When 
she  awoke  the  following  morning  she  had  complete  loss  of  memory 
of  everything  that  had  occurred.  I saw  her  four  days  later,  when 
she  had  recovered  all  her  vigour  and  the  vivacity  of  spirit  for  which 
she  was  known,  but  she  could  not  remember  entering  the  auto-car 
at  Rome,  or  the  long  stretch  covered  on  the  road  to  Porto  d’Anzio. 
Her  recollections  were  somewhat  confused,  and  ceased  about  two 
hours  before  her  departure  from  Rome.  On  the  other  hand,  she 
remembered  nothing  about  the  hospital  in  which  she  had  regained 
consciousness  and  spoken  with  the  doctors  ; nothing  of  her  removal 


268 


PSYCHIATRY 


to  her  own  house,  or  of  the  first  day  that  she  passed  there,  wherJ 
she  spoke  to  the  members  of  her  own  family  (amnesia  retrograda  i 
anterograda). 


The  literature  of  the  subject  can  now  show  a great  number  oil 
cases  of  amnesia  retrograda,  anterograda,  and  retro-anterograda,! 
I have  added  to  the  bibliography  of  the  phenomenon  two  unpub- 
lished cases  that  are  very  instructive  to  the  reader.  The  inter-: 
pretation  of  the  phenomenon  itself  presents  great  difficulties. 

Why  should  an  individual  who  has  risen  from  bed  in  perfed 
health,  has  thought  and  acted  regularly  from  six  till  nine  in  tffi; 
morning,  after  meeting  with  an  accident  at  nine,  not  be  able,  wher 
he  recovers  consciousness,  to  take  up  the  thread  of  his  life  at  tffii 
hour  of  the  accident  ? Why  can  the  thread  be  resumed  only  at  a| 
point  several  hours  earlier  ? | 

I suppose  that  the  whole  series  of  thoughts  succeeding  om| 

1 

I 


V 


!| 

another  in  consciousness  over  a longer  or  shorter  period,  in  a par-! 
ticular  disposition  of  the  mind  and  with  a. particular  objective 
are  lost.  This  leads  to  the  predominance  of  an  imaginative  proii 
duct,  with  which  are  closely  bound  up  many  thoughts  and  act^ 
formed  and  carried  out  during  a longer  or  shorter  tim,e.  I 

Let  us  suppose  that  the  officer  whose  case  I have  mentioned^i 
when  he  awoke  in  the  morning,  was  thinking  of  his  excursion  or| 
horseback,  and  represented  to  himself  the  places  he  would  pass! 
through  (w)  and  the  point  he  would  make  for  (x)  ; that  he  wasj 
occupied  with  his  toilet,  enjoying  the  pleasure  of  thinking  what 
a figure  he  would  make  on  horseback  (y),  and  that  he  gave  various 
orders  all  relating  to  his  sport — a,  h,  c (see  Fig.  62).  We  shall 
then  have  a complete  organic  consciousness,  of  which  no  part  can 
stand  alone.  j 

Further,  the  consciousness  is  wholly  occupied  by  that  series 
of  images,  emotions,  and  acts,  which,  taken  all  together,  form  a 
conscious  thought  of  longer  or  shorter  duration,  commencing  in 
the  case  of  the  officer  at  six  in  the  morning,  and  projecting  itsell' 
forward  to  twelve  noon,  the  hour  fixed  for  his  return  home. 


I PHYSIO-PATHOLOGY  OF  MEMORY  269 

In  the  diagram  this  state  of  consciousness  is  represented  by  the 
circles  a,  h,  c,  w,  y,  x,  which  constitute  a whole  in  association, 
i If  the  accident  ruptures  this  state  of  consciousness  along  the 
; line  op,  let  us  suppose  at  nine  o’clock,  then  the  single  components— 
: which  have  no  separate  existence,  but  form,  part  of  the  whole 
1 that  is  definitely  and  violently  broken  through  along  op,  and  which 
therefore  ceases  to  exist — cannot  be  represented  in  another  state 
i of  consciousness. 

It  is  well  to  admit  that  such  an  interpretation  is  only  hypo- 
thetical, and  perhaps  not  applicable  to  all  cases.  Contrary  to  the 
supposition  of  D’Abundo  that  ammesia  retrograda  does  not  involve 
any  event  that  has  forcibly  impressed  or  interested  the  subject, 
there  are  cases,  such  as  that  related  by  Brown-Sequard  and  reported 
by  Ribot,  in  which  the  amnesic  period  covers  events  that  are  really 
central  points  in  the  life  of  every  person,  such  as  marriage. 

Sometimes  immediately  after  the  psycho-epileptic  attack  the 
recollection  of  part  or  of  the  whole  of  what  happened,  or  of 
what  the  subject  did,  persists.  This  recollection  lasts  only  a short 
time,  disappearing  later  on,  and  the  subject  can  never  recall  it. 
especially  if  an  epileptic  attack  intervenes  between  this  state  and 
the  normal.  The  probable  explanation  is  that  the  state  of  con- 
sciousness characterizing  the  psycho-epileptic  attack  continues  for 
som,e  tim,e  longer,  and  so  the  subject  remembers,  as  does  the  som- 
nam,bulist,  what  cannot  be  recalled  after  the  recovery  of  normal 
consciousness  (ammesia-anterograda). 

Among  very  numerous  cases  I remember  one  of  severe  epilepsy, 
in  which  the!  subject  one  morning,  without  any  reason  whatever, 
killed  his  wife  by  repeated  blows  with  an  axe.  He  remained  im- 
passive in  his  own  room  beside  the  dismembered  corpse.  When 
the  gendarmes  came  up  just  after,  he  recounted  the  whole  matter 
in  detail,  and  justified  his  crime  after  the  m,anner  of  an  epileptic. 
A little  later  he  was  seized  by  a convulsive  fit,  and  after  it  he 
remem,bered  nothing,  nor  could  he  explain  to  himself  why  he  had 
killed  his  wife,  although  he  had  given  reasons  in  detail  to  the  police 
(amnesia  retrograda-anterograda). 

Cases  of  ammesia  anterograda  are  more  intelligible  if  we  admit 
the  duplication  of  the  consciousness,  as  in  somnambulism,. 

The  sam,e  thing  happens  in  some  cases  of  hysteria  and,  generally 
speaking,  always  where  the  brain  is  disordered  in  consequence  of 
a strong  nervous  discharge,  in  which  case  it  works  within  a very 
circumscribed  range  of  psychic  activities,  in  a spasmodic  state, 
and  furnishes  associations  that  are  not  usual  to  the  norm,al  psychic 
personality.  When  the  personality  has  reassum,ed  its  legitim,ate 
power  over  all  its  conscious  m,ental  acquisitions,  the  spasm  or  the 
.constriction  being  over,  a free  path  being  open  to  the  psycho-sensory 
waves  and  to  the  norm,al  em,otions,  and  the  paths  of  association 
being  restored,  the  individual  can  recollect  nothing  that  is  not  an 


270 


PSYCHIATRY 


emanation  of  something  that  is  truly  part  of  the  order  of  ideas 
and  tendencies  of  his  personality.  Since  all  the  moral  and  intel- 
lectual acquisitions,  the  acts,  and  the  sensations  of  this  state  of 
spasm  of  consciousness  are  in  contradiction  to  the  personality,  or  ! 
have  not  assumed  any  relations  with  it,  they  are  therefore  not 
reproducible. 

Periods  of  general  amnesia  are  sometimes  observed  as  the 
culmination  of  a syndrome  that  has  remained  isolated  as  an 
episode  in  life,  or  is  repeated  several  times  at  longer  or  shorter 
intervals. 

' I here  report  an  observation  made  upon  a patient  affected  by 
a psychopathic  syndrome  that  is  a masked  form  of  epilepsy,  and 
might  be  characterized  as  amnesic  insanity.  I 

Vet.  Luigi  di  Giuseppe  of  Naples,  aged  thirty-nine  years,  j 
unmarried,  a waiter  by  profession,  was  admitted  to  the  Provincial 
Asylum  for  the  first  time  on  January  14,  1894.  Nothing  is  known 
of  his  family  history.  When  he  was  a few  months  old  he  had  con- 
vulsions for  the  first  time,  and  as  a result  one  eye  became  atrophied  ( ? ). 
He  was  always  of  melancholy  disposition.  After  receiving  an 
elementary  education,  he  attempted  to  learn  the  business  of  a 
hatter,  but  had  to  give  it  up,  owing  to  defective  sight.  For  the 
same  reason  he  had  to  cease  working  as  a tailor,  and  he  then  com- 
menced to  act  as  a waiter.  At  twenty-four,  he  had  a fit  of  pro-  ‘ 
found  depression  ; he  attempted  to  commit  suicide,  but  his  courage  = 
failed  him.  Shortly  after  this  attempt  he  left  his  home,  and  was 
found  on  the  Campo  di  Marte.  Of  this  he  has  no  recollection.  At  'I 
thirty-four,  he  went  to  America  and  remained  there  three  years. 
He  then  returned  to  Italy  and  continued  steadily  at  work.  In  | 
November,  1893,  however,  he  began  to  suffer  from  a certain  weariness 
and  depression,  and,  as  he  himself  expressed  it,  he  had  no  memory. 
It  became  part  of  his  duty  to  follow  his  master  to  the  country  for  . 
a month,  and  he  there  declared  that  he  was  incapable  of  serving  ■ 
him,  which  caused  him  much  affliction.  On  December  26,  1893,  j 
he  received  a certain  order  from  his  master,  and  this  caused  him  \ 
considerable  uneasiness.  He  showed  signs  of  agitation,  left  the  1 
house,  and,  without  any  reason  at  all,  went  to  Baiano,  covering  I 
many  kilometres  on  foot.  He  had  left  Naples  at  ten  in  the  mmrning, 
and  at  eight  at  night  the  police  saw  him  in  the  district  mentioned, 
looking  wildly  about,  and,  as  he  could  give  no  coherent  account  of 
himself,  they  took  him  to  the  police  office.  He  remained  in  a 
dazed  condition,  without  sleeping,  until  the  next  day.  In  the 
course  of  the  morning,  after  he  had  been  questioned  several  times, 
he  showed  astonishment  on  finding  himself  in  that  place  and  in 
a district  that  was  unknown  to  him.  He  told  his  name,  but  could 
give  no  reason  for  his  journey.  He  was  three  da^^s  without  eating, 
taciturn,  sorrowful,  and  a prey  to  great  anxiety.  On  the  fourth 
day  a brother  came  to  see  him.  The  sufferer  recognised  him,  but 


PHYSIO-PATHOLOGY  OF  MEMORY 


271 


could  not  remember  anything  that  had  happened  to  him  during 
the  past  four  days.  He  burst  into  tears,  saying  : ‘ If  my  malady 
were  known,  endless  misfortune  would  befall  me.’  After  he  had 
returned  to  Naples  and  recovered  his  normal  health,  he  wished  to 
take  service  elsewhere,  and  was  engaged  by  a gentleman  in  Somma, 
but  after  three  days,  instead  of  going  there,  he  went  elsewhere, 
was  seized  with  the  greatest  anxiety,  took  no  food  for  three  days, 
and  had  aural  hallucinations.  He  imagined  he  heard  his  master 
whistle,  and  would  run  to  the  window,  calling,  ‘ Wait,  wait  !’ 
Sometimes  he* would  say  that  he  wished  to  go  to  America. 

He  had  no  recollection  of  these  occurrences. 

On  the  occasion  of  this  second  fit,  on  January  14,  1894,  his 
family  sent  him  to  the  asylum.  There  the  patient  was  calm,  but 
heedless  of  everything.  He  did  not  recognise  his  own  condition 
or  the  nature  of  his  surroundings.  He  kept  himself  huddled  up  in 
bed,  looking  suspicious  and  dejected.  On  being  questioned  he  gave 
always  the  same  answer  : ‘ Let  me  go.  I must  start  for  America. 
My  friends  are  calling  me.’ 

From  his  attitude  and  his  air  of  suspicion  it  was  inferred  that 
the  patient  was  a prey  to  hallucinations,  the  nature  of  which  he 
wished  to  keep  hidden.  He  was  incoherent  and  confused.  For 
two  days  he  refused  food,  and  he  was  for  a long  time  without  sleep. 

On  physical  examination  he  showed  the  following  character- 
istics : irregular  contractions  of  the  oro-labial  muscles,  especially 
the  elevator  of  the  lip  on  the  left  side,  when  he  spoke  ; his 
articulation  of  r was  not  very  marked  (rotacism). 

From  January  18  he  commenced  to  improve,  and  on  the  20th 
he  was  able  to  recognise  the  place  he  was  in,  and  seemed  to  suffer 
much  on  finding  himself  in  an  asylum.  However,  he  maintained 
his  dejected  and  suspicious  airs,  and,  what  was  a matter  of  impor- 
tance, he  showed  a complete  loss  of  memory  of  a long  period  of  time. 
He  thought  that  it  was  December  26,  and  remembered  nothing 
subsequent  to  the  moment  when  he  received  the  order  from  his 
master  and  went  to  Baiano.  His  recollections  connected  them- 
selves perfectly  with  the  day  preceding  his  flight  to  Baiano,  but 
from  that  time  on  up  to  January  20  nothing  was  reproducible. 

For  some  time  his  memory  remained  weak,  but  it  improved 
during  the  month  of  February.  His  personality  was  gradually 
recomposed,  and  the  deficiency  of  memory  became  more  restricted. 
It  was  limited  to  the  day  of  the  first  fit— he  did  not  recollect  what 
happened  to  him  from  the  26th  to  the  27th— and  to  a few  days  of 
the  second  fit,  for  he  could  recollect  nothing  from  January  15  to  20. 

Though  attempts  were  made  to  give  him  connecting  facts  for 
the  two  periods  mentioned,  the  two  lacunae  were  never  filled  up. 

As  he  showed  no  further  disorder,  he  was  dismissed  from  the 
asylum  on  March  4,  1894. 

Three  days  afterwards  he  was  again  admitted,  in  a state  of  great 


272 


PSYCHIA  TRY 


agitation.  He  was  weeping,  and  did  not  recognise  the  place  to  which  ^ 
he  had  been  brought.  He  commenced  to  improve  almost  im- 
mediately, but  he  was  never  able  to  recollect  that  he  went  to  his  | 
brother’s  house,  or  the  agitated  nights  he  passed  there.  Amnesia 
of  the  period  passed  in  that  house  continued.  He  remained  in 
the  asylum  until  April  29. 

On  August  13,  1900,  he  was  brought  back  to  the  asylum,  for 
reasons  similar  to  the  foregoing.  The  patient  said  that  from,  tim,e 
to  tim,e,  in  the  midst  of  his  work,  he  suffered  from  mental  disturb- 
ances, not  knowing  where  he  was  or  what  he  was  doing.  These 
disturbances  arose  without  any  cause  whatever,  and  sometimes 
happened  several  times  in  a day,  until  he  would  fall  into  extrem,e 
confusion.  He  was  never  in  convulsions.  During  these  attacks 
he  always  did  strange  things,  without  having  any  recollection  of 
them.  He  would  run  away  from,  the  house  and  go  into  places  quite 
unknown  to  him,.  Once,  in  1897,  he  went  to  Nocera  on  foot.  In 
the  last  few  years  his  history  presents  num,erous  long  periods  of 
complete  aminesia. 

The  most  classical  form,  of  total  or  tem,porary  loss  of  mem,ory 
is  that  presented  by  the  so-called  duplication  of  personality . The 
history  of  hysteria  and  of  somnambulism,  furnishes  very  considerable 
material  in  the  way  of  observation  of  individuals  who,  under  given 
circumstances,  show  a change  of  personality,  which  is  characterized  ’ 
in  its  new  state  by  new  aptitudes,  unusual  ideas,  a new  m,ode  of 
feeling,  a new  attitude,  and  new  form,s  of  reaction.  Those  pre-J; 
senting  this  phenomenon  have  perceptions  and  norm,al  relations  || 
with  the  external  world  ; they  recollect  their  past  in  such  a way 
that  the  primary  consciousness  continues  in  the  second  state  with-  t ; 
out  interruption.  If  after  a certain  time  they  leave  this  second 
state  and  reassum,e  the  primiary,  they  do  not  recollect  all  the  period 
of  time  in  which  they  were  in  the  state  B,  if  we  represent  the  normal  ; 
state  by  A.  The  mom,ent  at  which  they  pass  into  that  new  state  ^ 
of  consciousness,  designated  B,  is  reattached  to  the  m,om,ent  at  || 
which  they  return  to  A,  the  whole  interval  of  the  state  B — it  m,ay  ' 
be  hours,  days,  weeks,  m,onths,  or  even  a year — disappearing  com,-  I 
pletely  from,  memory,  and  rem,aining  incapable  of  reproduction.  * 

During  this  phase  the  subject  may  do  a num,ber  of  things  that 
are  rational  and  logical,  just  like  the  action  of  any  normal  i 
man,  but  of  these  there  will  be  no  recollection  when  the  sufferer 
returns  to  his  primary  state.  ’ 

The  most  original  and  interesting  case  in  the  whole  literature  ’ 
of  the  subject  is  that  of  Camuset,  reported  by  Voisin.  The  subject 
was  a certain  V.  Lois,  seventeen  years  of  age,  son  of  a woman  of  ; 
evil  life  From  childhood  he  had  been  given  to  vagabondage  and 
begging.  A few  years  prior  to  observation  he  had  been  arrested  j 
for  theft,  and  taken  to  the  reformatory  of  Saint  Urbain.  There  i 
he  worked  in  the  helds,  but,  falling  ill,  he  was  transferred  to  the  ; 


PHYSIO-PATHOLOGY  OF  MEMORY 


273 


asylum  of  Bonne val,  suffering  from  paralysis  and  atrophy  of  the 
lower  limbs.  In  the  asylum  he  was  considered  a respectable  youth,, 
of  good  character,  gentle  and  grateful ; he  awakened  much  interest 
by  the  recital  of  the  story  of  his  past  life,  and  of  the  thefts  he  had 
committed  ; also  by  his  protestations  that  for  the  future  he  was  ‘ 
determined  to  be  honest. 

He  remembered  everything  that  had  happened  to  him  in  the 
reformatory  of  Saint  Urbain,  his  friends  there,  the  work  that  had 
been  given  him,  and  he  told  a touching  story  how  one  day,  when 
he  was  lifting  a bundle  of  faggots,  he  had  taken  into  his  hand 
a serpent,  which,  however,  slipped  away  without  biting  him. 
Consequent  on  his  emotion  he  suffered  convulsions  and  loss  of 
power  in  the  lower  limbs,  and  therefore  had  to  be  transferred  to 
Bonne  val.  He  remembered  well  his  impressions  on  passing 
through  Paris. 

As  he  had  paraplegia,  in  the  asylum  he  was  put  to  learn  the 
profession  of  tailoring,  in  which  he  made  rapid  progress.  About 
a year  elapsed,  and  one  morning,  when  he  was  working  in  the  tailors’ 
shop,  he  had  a severe  fit  of  hysteria,  that  passed  through  various 
phases,  and,  with  its  repetitions,  lasted  about  sixty  hours.  When 
the  fit  was  over  he  wished  to  rise  and  dress  himself  ; he  asked  for 
his  clothes,  dressed  partially,  took  a few  steps  in  the  room — evidently 
the  paraplegia  had  disappeared — and  called  for  his  companions  to  go 
to  work  in  the  fields.  He  thought  that  he  was  at  Saint  Urbain. 
He  did  not  recognise  either  the  doctors  or  the  nurses,  or  even  his 
comrades  at  Bonne  val.  He  would  not  admit  that  he  was  paralyzed, 
and  he  could  remember  only  that  ‘ the  other  day  he  w'as  much 
frightened  by  a serpent  that  he  had  taken  in  his  hands.’  He  re- 
membered  nothing  of  his  removal  to  Bonneval  or  of  the  time  he 
had  passed  there  ; nor  had  he  any  recollection  of  his  passage  through 
Paris,  or  of  the  tailors’  shop,  or  of  the  art  of  tailoring  that  he  had 
learned.  He  said  that  they  were  trying  to  make  fun  of  him.  At 
the  same  time  his  character  became  completely  changed  ; the  same 
disposition  that  he  had  shown  when  he  was  detained  at  Saint  Urbain 
returned,  so  that  he  became  querulous,  ungrateful,  of  bad  conduct, 
and  arrogant.  The  lacuna  of  memory,  extending  over  a year, 
always  remained  with  him. 

Many  years  ago  I had  under  my  charge  at  Naples  a Jewish  girl  of 
seventeen  years,  who  used  to  fall  into  a somnambulic  phase  from 
time  to  time  in  the  course  of  the  day,  often  without  any  definite 
cause  and  without  preceding  convulsions.  This  would  happen 
when  she  was  in  the  midst  of  some  domestic  work.  The  people  of 
the  house  noticed  nothing  but  her  change  of  disposition,  and  also 
that  if  engaged  in  conversation  she  would  break  off,  or  if  she  was 
working  at  embroidery,  as  was  her  custom,  she  would  stop  her 
work,  go  into  the  kitchen,  and  start  housework.  At  other  times  she 

18 


274 


PSYCHIATRY 


would  begin  an  animated  conversation  with  a sister  who  was  not  in 
the  house. 

If  those  present  attempted  to  draw  her  into  conversation,  she 
would  take  part  in  it,  but  in  a most  monotonous  fashion,  without 
spontaneity  and  without  initiative,  like  some  person  who  was 
absorbed  in  a matter  extraneous  to  the  conversation.  When  she 
reawakened,  she  used  to  wonder  at  not  finding  herself  in  front  of 
the  embroidery  frame,  at  which  she  remembered  she  had  sat  down 
to  work.  She  recollected  nothing  of  what  she  had  seen,  heard, 
said,  or  done  during  the  interval. 

When  I was  teaching  in  the  University  of  Palermo  I saw  a very 
intelligent  girl,  the  daughter  of  one  of  my  colleagues,  who  was 
affected  by  a variable  and  extensive  hysteric  syndrome,  having  but 
recently  recovered  from  amblyopia  hysterica.  Every  evening,  almost 
at  the  same  time,  the  girl  would  fall  into  a somnambulic  state,  and 
assume  a psychic  attitude  decidedly  different  from  her  ordinary. 

She  changed  from  a sad,  preoccupied,  unexpansive,  fastidious 
and  torpid  individual  to  a good-humoured  person,  expansive,  lively, 
and  active.  She  lived  in  a village,  and  one  evening  her  brother 
arrived  from  Palermo.  She  received  him  gladly,  kissed  him,  and 
talked  with  him,  as  had  been  her  custom  before  her  illness,  being 
very  fond  of  him.  In  this  disposition  of  mind  she  went  to  bed,  but 
when  she  arose  in  the  morning  she  was  astonished  at  meeting  her  ■ 
brother  there  ; she  asked  how  and  when  he  had  come,  and  re-  ; 
membered  nothing  of  her  conversation  of  the  past  evening.  She 
was  sad  and  irresponsive,  and  treated  him  with  coldness.  ^ 

This  condition  of  matters  lasted  about  a year,  and  during  that  • 
period  the  girl  was  conscious  of  only  half  of  the  time  that  she  lived — 
from  the  morning  until  four  in  the  afternoon. 

The  late  Professor  Tommasi  once  asked  me  to  examine  and  to  \ 
report  upon  a young  man  of  a strange  nature.  He  knew  him  as  a I 
neighbour,  and  was  interested  in  his  vagaries  and  in  his  illness.  Legal  | 
proceedings  were  instituted  against  this  youth  for  these  reasons.  « 
One  day  he  met  one  of  the  city  guards,  who  was  on  point  duty  at 
the  steps  leading  from  Via  Pontecorvo  to  Piazza  Dante,  and  invited, 
him  to  follow,  while  he  made  a perquisition  in  a house  in  that  street.  | 
At  first  the  policeman  was  uncertain  what  to  do,  but  the  youth  I 
ordered  him  to  follow,  giving  himself  out  as  a superior  officer  of  the  i 
Department  of  Public  Security,  and  the  man  obeyed.  They  made  | 
their  way  up  the  steep  street,  entered  the  gateway  N,  and  knocked  | 
at  the  door  of  the  house  occupied  by  Mr.  X,-  an  advocate,  who  was  • 1 
not  at  home.  The  lady  of  the  house  opened  the  door.  He  then  r 
said  to  her  : ‘ In  the  name  of  the  law,  I must  search  your  house  for  l| 
important  documents  that  are  believed  to  be  there.’  The  com-l| 
motion  into  which  the  poor  lady  was  thrown,  and  her  entreaties  hj 


PHYSIO-PATHOLOGY  OF  MEMORY 


275 


were  quite  ineffectual  in  stopping  him.  After  having  turned  over 
some  letters  and  books,  he  ordered  the  policeman  to  follow 
him.  They  left  that  house,  and,  when  they  had  reached  the 
slope  of  Pontecorvo,  he  ordered  the  guard  to  return  to  duty  at 
the  point  that  he  had  left,  while  he  himself  mixed  with  the  people 
on  the  Piazza  Dante.  In  consequence  of  this  affair  the  advocate 
lodged  a complaint,  and  proceedings  were  taken. 

The  accused  remembered  nothing  of  the  matter  with  which  he 
was  charged,  and  showed  extensive  lacunae  of  memory.  Among 
other  matters,  he  had  forgotten  the  period  and  the  circumstances  of 
his  marriage,  which  he  could  not  explain  to  himself,  and  about 
which  he  was  much  troubled.  He  was  acquitted.  This  case  bears 
a great  resemblance  to  that  related  by  Morton  Prinke  at  the  last 
International  Congress  of  Psychology. 

If  we  designate  the  normal  state  by  A and  the  state  we  shall 
call  abnormal  by  B,  we  find  that  the  state  B is  not  always  com- 
pletely forgotten.  In  some  cases  there  is,  as  it  were,  a half  con- 
sciousness of  that  period,  and  it  is  remembered  as  a dream,  some- 
times fragmentarily.  This  feature  is  often  met  with  in  pre-  and  post- 
epileptic psychic  states,  and  in  some  other  forms  of  epileptic  phrenosis, 
sometimes  also  in  hysteiia.  A decided  example  of  this  was  furnished 
by  the  Count,  whose  case  will  be  treated  more  in  detail  when  we  come 
to  speak  of  hysterical  phrenosis  in  the  third  part  of  this  book.  When 
the  Count  had  recovered  from  a rudimentary  state  B,  after  a con- 
vulsion, during  which  state  he  had  been  talking  a good  deal  about 
himself,  he  came  to  me,  who  had  observed  him  closely,  and  said  : 

I don  t know  how  ever  I could  have  thought  and  done  such  strange 
things.  . . . Everything  that  I said  and  did  seemed  to  me  to  be 
absolutely  true  . . . and  I remember,  as  in  a dream,  that  time, 
which  was  very,  very  different  from  my  real  life.  . . .’ 

The  same  thing  is  noticed  in  induced  somnambulism.  When 
all  is  said  and  done,  it  is  possible  to  bring  about  a transformation 
of  the  personality  by  hypnotic  arts,  and  all  the  impressions  received 
and  all  the  acts  performed  by  the  hypnotized  person  generally  pass 
out  of  memory  when  the  subject  returns  to  his  normal  state.  These 
things  are  remembered  only  when  the  hypnotic  state  returns, 
either  spontaneously  or  after  employment  of  the  means  by  which 
it  is  usually  provoked. 

Some  states  of  intense  mania,  some  phases  of  sensory  deliria, 
some  brief  episodes  of  melancholia  (raptus),  and  the  greater  number 
of  the  manifestations  of  acute  dementia,  especially  if  hallucinatory, 
and  of  several  other  psychopathic  states,  may  also  fail  to  be  rememJ 
bered  when  the  normal  personality  is  re-established. 

Under  this  aspect  polyneuritic  psychosis  (Korsakoff,  Colella) 
and  melancholia  deserve  particular  attention. 

In  polyneuritic  psychosis  the  sufferer  has  perceptions  of  the 

18—2 


276 


PSYCHIATRY 


external  world,  and  is  logical  in  his  speech  and  in  his  actions,  but 
in  a very  short  time  he  forgets  what  is  said  to  him  and  what  he 
himself  has  said.  A distinguished  lady  who  was  attacked  by 
this  malady  during  pregnancy  asked  me  the  same  thing  over  and 
over  again  without  intervals,  because  she  forgot  what  she  had  asked 
as  well  as  the  answer  I had  given  her.  In  m.elancholia  the  memory 
behaves  in  very  various  fashions. 

There  are  melancholic  subjects  who,  on  recovery,  repeat  the 
most  minute  particulars  of  what  has  happened  to  and  around 
them,  and  there  are  others  who  remember  the  long  period  of  their 
illness  only  as  a dream.  According  to  my  experience,  when  there 
have  been  hallucinations,  which  generally  induce  disgregation  of 
the  personality,  or  when  the  deliria  are  well  organized  and  have 
transformed  the  personality,  the  new  percepts,  that  assume  associa- 
tive relations  with  the  products  of  delirium,  are  remembered  only 
in  a confused  way,  when  the  deliria  disappear  and  the  former  normal 
personality  is  resumed. 

In  a melancholic  woman  the  change  of  kinaesthesis,  and  therefore 
of  the  nucleus  of  the  personality,  was  so  profound  that  she  did  not 
know  her  own  self,  and  she  was  unable  to  recognise  any  of  her 
belongings  or  her  relations,  including  even  her  husband.  She 
repeated  constantly  : ‘ This  m,an  keeps  coming  to  me  and  tries  to 
take  care  of  me,  but  he  is  not  miy  husband,  because  I was  never 
m.arried.  I am  not  Mrs.  X.  She  is  dead.  . . . Once  that  lady 
lived  . . . but  she  lives  no  longer.  They  call  me  by  that  nam,e, 
but  it  is  not  X who  is  speaking  to  you.’ 

‘ You,’  she  said  to  m,e — ‘it  seems  to  me  that  I know  you,  but  I 
cannot  say  who  you  are,  nor  do  I know  whom  you  came  to  see,  or 
when  I becam^e  acquainted  with  you.  If  you  are  coming  for  Mrs.  X, 
as  you  say,  you  are  mistaken,  because  she  is  no  longer  living.’ 

The  reason  of  the  phenomenon  is  different  in  the  different  cases 
recorded.  There  is  no  recollection  of  the  state  of  severe  mania, 
because  of  the  great  rapidity  with  which  im,pressions  and  thoughts 
follow  one  upon  another ; and  further,  there  is  not  sufficient  tim,e 
allowed  for  the  form.ation  and  the  fixation  of  the  percepts.  In  the 
raptus  melancholicus  it  is  the  emotive  tension  that  has  been  for 
long  preparing  the  nervous  discharge  of  the  inferior  centres,  which, 
as  Jackson  m.aintained  long  ago,  perform  their  functions  without 
the  dom,ain  of  consciousness. 

In  acute  dementia  there  is  a real  dissociation  of  the  personality, 
with  more  or  less  apparent  loss  of  its  more  complex  components, 
and  disaggregation  of  the  latter  into  their  simpler  elements  ; there 
is  also  a want  of  that  associative  process  which  is  the  condition 
of  perception,  and  therefore  of  memory. 

General  defects  of  memory  ma\^  be  congenital  or  acquired. 
Congenital  defects  appear  almost  exclusively  in  weak-mdnded 


PHYSIO-PATHOLOGY  OF  MEMORY 


277 


persons  whose  brain  is  so  constituted  as  not  to  offer  the  conditions 
necessary  for  the  fixation  of  the  impressions  of  the  external  world. 
The  conditions  required  for  the  formation  and  conservation  of  per- 
cepts, and  therefore  for  their  evocation  and  reproduction,  cannot 
be  realized.  Besides  the  partial  hypermnesias  already  spoken  of, 
whose  products  are  of  little  utility,  one  of  the  surest  character- 
istics of  the  feeble-minded  person  lies  in  his  weak,  fragmentary, 
and  uncertain  memory.  The  number  of  things  that  he  forgets  is 
enormous  in  proportion  to  what  is  found  in  a man  of  good  evolution. 
He  is  slow,  and  has  great  difficulty  even  in  his  fragmentary  repro- 
duction of  the  strongest  images,  unaccompanied  by  the  satellites 
that  in  greater  or  less  number  follow  in  their  orbit,  in  normal 
men.  His  notions  of  time  and  place,  if  he  has  such,  are  evanescent 
and  erroneous.  The  same  defect  of  power  and  of  material  for 
association  creates  a great  difficulty  in  the  evocation  of  the  mental 
content  at  his  command,  which  is  always  poor  with  regard  both  to 
objects  and  words. 

Acquired  loss  of  memory  is  always  the  expression  of  changed 
organic  conditions  of  the  brain.  In  whatever  manner  and  for 
whatever  reason  the  brain  departs  from  the  normal  conditions  of 
existence,  loss  of  memory  is  almost  always  the  most  conspicuous 
s\^mptom.  Acute  infective  maladies,  abundant  loss  of  humours, 
intoxication,  infection,  cerebral  shock,  exaggerated,  intense,  and 
unduly  protracted  intellectual  labour  (auto-intoxication),  all  give 
the  same  result. 

Those  neurasthenic  persons  who,  with  their  small  power  of 
resistance,  sometimes  due  to  heredity,  have  abused  their  energies 
in  one  way  or  another,  some  in  the  struggle  for  existence,  others 
in  the  orgies  of  pleasure,  lose  their  memory.  In  the  greater  number 
of  cases,  loss  of  memory  is  the  first  protest  lodged  in  the  bank  of 
consciousness,  on  account  of  a deficit  that  arises  from  outlay  in 
excess  of  the  original  capital  of  memory,  and  disproportioned  to 
the  reintegrative  power  of  the  nervous  elements,  which  latter  is  a 
condition  indispensable  to  the  maintenance  of  equilibrium  in  the 
balance  of  mental  life. 

Many  young  students  feel  that  they  have  become  more  or  less 
enfeebled,  not  only  in  their  power  of  attention,  and  therefore  of 
perception,  but  especially  in  their  power  of  retention.  This  happens 
often  after  the  leaving  examinations  of  the  lycees,  which  demand 
an  expenditure  of  labour  out  of  proportion  to  an  intelligence  which 
is  sometimes  poor,  and  to  a constitution  that  is  weak.  Such  youths 
learn  slowly,  and  have  difficulty  in  retaining  what  they  learn. 

The  phenomenon  of  defect  of  memory,  which  may  be  temporary 
in  some  less  serious  forms  of  neurasthenia,  is  capital  in  all  states  of 
mental  weakening,  of  whatever  nature  or  origin,  and  is  found  in  its 
highest  degree  in  dementia. 

Amnesia  based  upon  cerebral  degeneration  (states  of  primary 


27S 


PSYCHIATRY 


or  consecutive  dementia,  perhaps  also  neurasthenic  demientia)  is 
often  progressive.  Individuals  afflicted  by  it  gradually  forget  the 
better  part  of  what  formed  the  co-efflcient  of  their  psychic  person- 
ality. Their  mind  is  impoverished  ; their  recollections  become 
slower,  less  complete,  more  uncertain,  they  blend  together  and 
become  confused  ; consequently,  there  are  very  numerous  errors, 
due  to  substitution  in  the  memory,  and  the  exchange  for  one 
another  of  facts,  places,  times,  objects,  and  persons.  Para- 
mnesia becomes  very  frequent,  and  this  is  the  first  step  on  the  way 
to  the  so-called  delirium  of  recognition  and  to  the  dysmnesia  of 
Morselli. 

Sometimes  it  happens  that  the  subject  believes  that  he  perceives 
for  the  second  time  persons,  things,  places,  facts,  and  psychological 
states  that  are  in  reality  new  to  him.  This  state  of  mind  has  been 
known  for  a very  long  time,  especially  to  the  poets.  Dickens 
makes  his  hero,  David  Copperfield,  say  : ‘ And  the  strange  feeling 
(to  which,  perhaps,  no  one  is  quite  a stranger)  that  all  this  had 
occurred  before,  at  somie  indefinite  time,  and  that  I knew  what  he 
was  going  to  say  next,  took  possession  of  me.’ 

To  this  phenomenon  the  name  of  paramnesia  has  been  given. 
It  is  sometimes  associated  with  painful  emotional  states — gener- 
ally so,  according  to  Lalande  ; but  according  to  other  observers, 
including  myself,  this  is  not  the  most  usual  case,  for  it  is  a psychic 
phenomenon  in  no  way  emotive,  and  by  some  (Dugas)  it  is  not  even 
regarded  as  a pathological  fact,  x^gain,  according  to  some  observers 
this  phenomenon  is  quite  common,  almost  all  men  being  subject  to 
it  (Diedsens),  while  others  hold  that  it  is  met  with  in  only  30  per 
cent,  of  people  (Lalande),  and  a little  more  frequently  in  childhood, 
an  opinion  with  which  Dugas  agrees. 

The  phenomenon  of  paramnesia  is  complete  or  incomplete,  and 
it  is  very  difficult  to  explain.  Several  interpretations  have  been 
offered,  and  this  fact,  while  proving  that  the  m.atter  has  exercised 
the  ingenuity  of  psychologists,  shows  also  that  the  true  explanation 
is  not  yet  known. 

We  have  to  do  with  a double  representation,  in  which  the  stronger 
element  corresponds  to  the  subject  present,  while  the  weaker 
appears  to  be  projected  into  an  indeterminate  past. 

In  other  words,  perception  would  appear  to  be  first  unconscious 
and  then  conscious.  The  passage  into  consciousness  of  an  uncon- 
scious perception  gives  the  illusion  of  recognition  of  a veritably  new 
state  of  consciousness  (Lalande).  x\ccording  to  D’Aniel,  one  of 
the  two  representations  corresponds  to  the  sensation,  the  other 
to  the  perception. 

Sensation  and  perception  normally  succeed  one  another  within 
an  extremel}'  short  time,  but  where  there  is  paramnesia  the  interval 
would  appear  to  be  longer,  so  that  when  the  perception  is  completed 
In’  the  association  and  localization  of  the  sensation,  that  sensation 


PHYSIO-PATHOLOGY  OF  MEMORY 


279 


appears  already  known.  Dugas  seems  inclined  to  hold  that  par- 
amnesia enters  into  those  states  recognised  as  duplications  of  the 
personality,  and,  as  a matter  of  fact,  he  gives  the  example  of  a 
person  who  was  conscious  of  becoming  another  person.  One  of 
the  subjects  observed  by  him  used  to  say  : ‘ I heard  my  own  voice 
as  though  I had  been  listening  to  that  of  a stranger,  but  at  the  same 
time  I recognised  it  as  my  own,  and  I knew  that  it  was  I who  was 
speaking  ; but  the  ego  who  was  speaking  produced  on  me  the  effect 
of  a self  lost  long  ago  and  suddenly  rediscovered.’  Vignoli,  with 
whose  views  Soury  agrees,  makes  paramnesia  dependent  upon  the 
awakening  of  mental  images,  ideas,  and  sentiments,  through  associa- 
tion, by  the  rapidity  of  the  psychic  process,  and  by  the  rapidity  and 
constructive  power  of  the  imagination.  The  actual  image,  trans- 
ported by  an  unconscious  association  back  to  an  indeterminate 
and  distant  period,  appears  as  the  reproduction  of  past  perceptions. 
The  rapidity  of  the  psychic  process,  which  is  an  effect  of  the  facility 
with  which  a new  image  arises,  after  the  same  fashion  as  applies 
to  old  images,  causes  the  illusion,  when  the  subject  is  not  fully 
attentive,  which  makes  us  take  a fact  for  a recollection  (Biewliet). 
The  observations  of  Sander,  Pick,  Forel,  Kraepelin,  and  of  Bernard- 
Leroy  prove  the  frequent  occurrence  of  a dreamy  state  accompanied 
by  anguish  (Kraepelin).  Bourdon  attributes  the  majority  of  errors 
in  the  recognition  of  words  to  phonetic  analogies,  i being  confused 
with  /,  h with  p,  fer  with  mer,  etc.,  or  to  analogies  of  meaning. 

Fouillee  considers  the  sensation  of  the  ‘ seen  before  ’ as  a morbid 
phenomenon  of  echo  and  of  internal  repetition,  an  explanation  just 
as  obscure  as  that  of  Ribot,  who  writes  : ‘ For  my  part  I offer  the 
following  explanation  of  the  phenomenon.  The  image  formed  is 
very  intense,  and  is  of  a hallucinatory  nature.  It  imposes  itself  on 
the  subject  as  a reality,  because  there  is  nothing  to  rectify  the 
error.  In  consequence,  the  real  impression  is  relegated  to  the 
second  place,  with  the  colourless  character  of  a recollection,  and  so 
it  comes  to  be  localized  in  the  past.  This  hallucinatory  state, 
although  very  vivid,  by  no  means  annuls  the  real  impression,  but 
as  it  is  detached  from  that,  and  as  it  has  been  produced  very  rapidly, 
it  must  appear  as  a second  experience.’ 

Here  is  what  Thibault  says  on  the  point  : ‘ A perception  or  an 
emotion  actually  perceived  by  a subject  recalls  to  his  consciousness, 
under  the  influence  of  certain  causes — such  as  age,  weariness,  or 
intoxication,  all  of  which  induce  fugitive  excitation  of  one  form  of 
cerebral  activity  (the  subconsciousness) — an  analogous  perception 
or  emotion,  formerly  the  object  of  perception,  and  then  forgotten. 
This  recall  to  memory  through  analogy  is  wrongly  interpreted, 
because  of  its  brevity  and  its  rapid  return  to  oblivion. 

‘ It  is  accompanied  by  a particular  strong  affective  sentiment 
(due  to  some  unknown  cause),  which  gives  the  phenomenon  its 
vividness  and  its  originality,  and  which  cannot  be  controlled  by 


28o 


PSYCHIATRY 


the  momentarily  weakened  intelligence.  The  antecedent  percep- 
tion that  is  recalled  cannot  be  localized  in  any  fixed  period,  as  the 
phenomenon  of  memory  is  incomplete  and  very  short  ; so  it  comes 
to  be  relegated  to  a more  or  less  distant  period  of  the  past.’ 

I believe  that  the  influence  of  dreams  may  have  some  connec- 
tion with  the  phenomenon. 

The  illusion  of  having  ‘ seen  this  before  ’ may  give  rise  to  errors 
of  recognition,  even  to  the  extent  of  inducing  the  delirium  that 
bears  that  name  ; also  to  other  illusions  of  memory  with  which  the 
deliria  of  melancholic  subjects  are  related,  as,  for  example,  when 
they  attribute  to  themselves  faults  that  they  have  not  committed, 
or  when  they  state  that  they  have  been  hypnotized. 

Sometimes  it  is  the  imagination  that  formulates  conceptions, 
translated  into  words,  and  these  by  repetition  gradually  take  the 
place  of  a construction  identical  with  reality  (dysmnesia). 

This  phenomenon  reaches  its  maximum  degree  in  imbeciles  and 
in  insane  persons,  most  of  all  in  demented  subjects  who  are  still 
capable  of  composing  thoughts  and  of  having  apperception  of 
things  that  do  not  exist,  but  which  they  take  for  true.  Sometimes 
they  confound  the  false  products  of  the  acrrte  period  of  their  malady 
with  reality. 

It  is  a noteworthy  fact  that  idiots  have  a fuller  recollection  of 
the  few  images  at  their  command  than  imbeciles,  who  evoke  images 
with  more  difficulty,  and  falsify  the  mental  content. 

Whatever  be  its  explanation,  the  phenomenon  occurs  frequently 
even  among  sane  persons  ; but,  in  my  opinion,  it  is  always  a patho- 
logical phenomenon  of  memory.  It  may  also  be  held  that  there  ‘ 
is  a disturbance  of  the  perception,  in  so  far  as  perception  contains  : 
in  itself  the  fact  of  recognition,  and  consequently  a mnesic  disturb- 
ance, the  frequency  of  which  increases  with  the  mental  decay.  It 
is  very  common  in  primary  and  secondary  dementia,  and  most  of  ; 
all  in  dementia  paralytica.  , 

i 

General  defects  of  memory,  which  are,  as  a rule,  progressive,  ' 
usually  follow  a law  that  has  been  well  formulated  by  Ribot.  ' 

The  latest  acquisitions,  which  are  necessarily  the  least  stable,  ‘ 
as  they  have  not  had  time  to  organize  themselves  and  to  assume 
binding  associations  with  the  others  making  up  the  psychic  per- 
sonality, are  the  flrst  to  disappear,  so  that  in  loss  of  memory  the 
process  is  the  opposite  of  that  of  the  evolution  of  the  personality. 

The  latest  facts  are  usually  the  first  to  pass  into  oblivion, 
whilst  eailier  acquisitions,  and  especially  the  central  points  of  the 
histoiy  of  the  personality,  wffiich  form  a sort  of  mnesic  routine, 
and  w’hich  have  had  time  to  assume  more  numerous  relations  of 
association  wath  the  various  psychic  contents  at  the  time  of  the 
diffeient  historic  events  touching  the  personality,  are  much  more 
easily  and  readily  remembered. 


PHYSIO-PATHOLOGY  OF  MEMORY 


281 


In  the  process  of  dissolution  of  the  mind  and  in  the  progressive 
decay  of  the  memory  power,  these  appear  as  fragments  of  an  edifice 
that  has  fallen  to  ruin,  testimonies  sometimes  of  mental  opulence 
and  of  good  architecture,  like  the  articles  left  in  the  salon  of  a 
decayed  aristocrat,  whose  extreme  poverty  has  caused  something 
to  be  sent  to  the  brokers  every  day.  This  general  law  is  subject 
to  certain  exceptions.  It  is  not  to  be  taken  absolutely,  because  past 
memories  are  not  alwa37S  preserved,  nor  are  ah  of  them  retained — 
onty  a few,  indeed,  and  those  the  strongest  and  most  emotional. 
Many  disappear  and  others  fade  away,  the  particulars  being  lost 
or  confused,  while  illusions  of  memory  are  frequent.  On  the 
other  hand,  recollections  of  childhood  and  of  youth  are  almmst  all 
lost.  Until  the  personality  is  fuhy  constituted,  the  records  of  the 
period  of  evolution  are  colourless,  dull,  few  in  number,  imperfect,  and 
unconnected.  In  traumatic  psychosis,  for  example,  images  and 
recollections  of  particular  objects  are  for  the  most  part  lost,  whilst 
concepts  and  general  ideas  are  preserved. 

. This  law  is  demonstrated  in  a wonderful  fashion  by  the  way  in 
which  disgregation  of  the  complicated  organism,  of  speech  takes 
place.  It  is  known  that  nouns  are  the  earliest  to  be  forgotten, 
whilst  adjectives  and  verbs  offer  more  resistance.  The  reason  of 
this  lies  in  the  fact  that  the  network  of  associations  of  the  noun  is 
of  little  extent  in  comparison  to  that  of  adjectives  and  verbs.  At 
bottom  the  noun  has  little,  and  sometimes  nothing,  of  substantial 
relation  with  the  object  designated.  I do  not  know  why  table  is 
called  table,  or  why  paper  is  called  paper.  It  is  different  with  verbs 
and  adjectives,  which  indicate  relations  and  qualities.  Owing  to 
the  process  of  comparison,  these  assume  more  numerous  and  ex- 
tended mental  relations,  and  are  therefore  much  more  frequently 
called  up.  Words  composed  of  several  syllables  disappear  in  many 
cases  more  readily  than  simpler  words,  the  latter  of  which  are  also 
the  first  to  be  learned.  The  accented  vowel  of  each  syllable  is  re- 
membered better  than  the  word  as  a whole,  and  often  enables  the 
whole  word  to  be  recalled.  When  an  individual  knows  several 
languages,  those  learned  latest  are  the  first  to  be  forgotten,  and  his 
own  language,  the  very  dialect  he  spoke  in  childhood,  is  often  the 
last  form  of  speech  that  the  decayed  personality  retains  at  its  com- 
mand. I have  known  individuals  who  knew  Latin,  Greek,  and 
Italian,  but  who  slowly  forgot  those  languages  one  by  one,  according 
as  they  had  been  less  thoroughly  learned  or  less  often  put  to  use, 

; until  finally  they  were  reduced  to  their  own  dialect,  while  even  that 
;was  more  or  less  impoverished. 

I We  must  remember  how  easily  the  memory  of  demented  persons 
;is  exhausted.  When  a conversation  is  opened  with  them,  their 
first  replies  are  often  to  the  point — Le.,  show  the  possession  of  an 
intellectual  patrimony  that  is  still  considerable  ; but,  after  a few 
questions,  they  commence  to  wander.  Here  we  find  difficulty  of 


282 


PSYCHIATRY 


evocation  and  of  reproduction,  owing  to  which  only  a small  part  of 
the  residual  patrimony  can  be  utilized  ; above  all,  there  is  difficulty 
in  associating  recent  perceptive  formations  with  earlier  ones. 
It  is  this  difficulty  of  association  that  explains  why,  in  states  of 
mental  enfeeblement,  recent  products  disappear  more  rapidly  than 
those  acquired  earlier,  the  latter  having  at  command  a more  exten- 
sive network  of  association  that  facilitates  their  evocation  and 
reproduction,  even  when  they  seem  to  have  been  lost.* 

In  states  of  weakness,  as,  for  example,  during  convalescence  from 
acute  maladies,  evocation  is  slower  and  more  difficult.  This  may 
depend  upon  the  smaller  number  of  associated  percepts,  and  the 
consequent  inferior  intensity  of  the  waves  exciting  the  activity  of 
the  centres  of  reproduction,  which  latter,  for  the  same  reason,  are 
also  found  to  possess  a weaker  functional  potential. 

Thus  it  is  that  demented  persons  who  are  ill-nourished,  and  in 
whom  the  mnesic  process  seems  to  be  completely  ruined,  are  no 
sooner  put  under  a regime  that  favours  their  nutrition  than  the 
memory  begins  to  improve  also.  (The  same  holds  good  with  regard 
to  sane  persons.) 

In  this  case  reproduction  depends  upon  the  concourse  of  a 
greater  number  of  associated  ideas,  and  this  is  proved  by  the  fact 
that  when  the  power  of  evocation  is  inefficient,  even  in  sanity,  a 
large  number  of  collateral  images  are  voluntarily  evoked,  by  help 
of  which  the  subject  finally  manages  to  recall  the  image  temporarily 
lost. 


Sometimes  there  are  illusions  of  mem^ory,  as  when  we  judge  a fi 
past  event  that  has  made  a deep  impression  upon  us  to  be  very  '| 
recent,  or  when  we  think  that  a very  long  time  has  passed  since  the  | 
happening  of  some  events  of  little  importance,  the  recollection  of  .| 
which  has  partially  faded.  ? 

In  these  cases  memory  suffers  most  in  the  process  of  localiza- { 
tion  in  time.  Some  insane  persons  who  have  vague  recollections,  ;| 
or  none  at  all,  of  their  childhood,  occasionally  afhrm  that  they  were 
born  1,000  or  3,000  years  ago,  or  that  they  were  never  born  at  all.  |j 


Sometimes  the  subject  forgets  what  he  has  thought,  said,  or 
written,  and  when  he  thinks,  says  or  writes  it  again,  it  seems 
to  him  that  he  does  so  for  the  hrst  time.  The  preacher  mentioned 
by  Ribot  repeated  from  his  pulpit  the  same  sermon  that  he  had 
delivered  the  previous  week,  and  felt  quite  certain  that  he  had  been 
saying  something  totally  different.  Moury  once  wrote  some  reflec-  > 

* The  fact  that  the  mnesic  patrimony  of  demented  persons  is  not 
altogether  lost,  but  is  in  great  measure  simph^  buried  and  capable  of  being  j 
recovered,  induced  me,  a long  time  ago,  to  believe  that  many  cases  of  , 
dementia  could  be  restored  to  health  by  special  methods  of  mnemotechnics. 
As  far  as  possible,  this  is  now  being  practised  in  my  clinique.  | 


PHYSIO-PATHOLOGY  OF  MEMORY 


283 


tions  on  a question  of  political  economy,  but  lost  his  manuscript, 
and  did  not  write  it  out  again.  On  being  asked  to  send  his  article 
to  a review,  he  set  to  work  a second  time  and  believed  that  he  had 
thought  out  a new  way  of  treating  the  subject.  ‘ Two  months 
afterwards,’  he  writes,  ‘ I happened  to  find  the  lost  sheets.  Great 
was  m}^  surprise  on  finding  here,  almost  word  for  word  and  in  the 
same  phraseolog3^  what  I had  hitherto  believed  was  the  product 
of  my  very  latest  reflections.’ 

Decay  of  memory  may  be  slow  or  rapid.  An  example  of  rapid 
loss  of  memory  is  often  found  after  the  apoplectiform  seizure  with 
which  progressive  paralysis  is  frequently  initiated. 

As  a rule  it  is  diffuse  lesions,  sometimes  fine  alterations  of  the 
brain,  not  localized,  that  give  rise  to  such  mnesic  decadence.  There 
exists,  however,  a form  of  general  amnesia  dependent  upon  extensive 
lesions  of  the  frontal  lobes.  This  I have  already  described  in  a 
paper  published  in  Brain,  1895,  ‘ On  the  Functions  of  the  Frontal 
Lobe.’ 

I am  now  able  to  report  an  example  of  this  form  of  amnesia, 
consequent  upon  traumatic  lesion  of  the  frontal  lobes.  I believe 
that  few  similar  cases  prove  so  mmch,  or  reproduce  in  the  clinique, 
just  as  with  the  experimental  method,  a syndrome  that  is  clear! 3^ 
recognisable. 

Ber.,  of  Naples,  aged  twenty-six,  unmarried,  shoemmker  by 
trade,  with  an  elem,entary  education,  was  sent  to  the  asylum  from 
the  prison  of  San  Francesco,  where  he  had  been  detained,  after  his 
conviction  for  resisting  the  police. 

At  sixteen  years  of  age  he  had  been  condemned  to  three  years’ 
imprisonmnent  for  stabbing,  and  before  he  was  twenty,  he  was  again 
tried  for  brawling. 

In  August,  1894,  in  another  fray,  he  was  struck  by  a revolver 
bullet  that  entered  the  right  temple  and  issued  through  the  left 
frontal  protuberance.  He  slowly  recovered  after  treatment  in 
the  Hospital  of  the  Pellegrini.  When  received  into  the  asylum  he 
was  quite  calm,  and  thought  that  he  had  com,e  into  a prison,  but 
that  did  not  trouble  him,  and  he  allowed  himself  to  be  examined  and 
led  into  the  observation-room  with  the  greatest  indifference. 

On  objective  examination  he  shows  a cross-shaped  cicatrix  on 
the  left  temporal  region,  and  another  cicatrix  on  the  left  frontal 
region. 

The  examination  as  to  sensibility  in  all  its  forms  and  as  to  move- 
ment reveals  no  anomaly. 

The  pupillary  reflexes  are  normal  and  the  patellar  reflexes 
slightly  exaggerated. 

On  psychic  examination  he  appears  to  be  in  a dazed  condition. 
Always  alone,  avoiding  company  and  conversation,  he  is  to  be 
found  either  stretched  at  full  length  on  his  bed  or  wandering  about 


284 


PSYCHIA  TRY 


I 


in  the  hall,  like  a person  who  cannot  tell  where  he  is.  He  is  un- 
decided in  everything  he  does.  When  questioned,  he  always  gives 
an  answer,  and  often  to  the  point,  showing  on  a first  glance  regular 
perceptions  and  quite  a ready  attention  to  simple  matters,  but  this 
lasts  only  for  a short  time.  Confronted  with  facts  somewhat  less 
common  and  more  complex,  he  remains  mute  and  perplexed.  He 
cannot  explain  certain  positions  that  are  created  for  him,  but 
becomes  embarrassed  and  confused.  His  defective  attention  becomes 
evident  on  conversation  with  him.  He  often  stops  short,  does  not 
know  what  to  say,  turns  his  face  the  other  way,  is  easily  distracted, 
and  it  is  necessary  to  give  him  hints  to  bring  him  back  to  the  original 
subject.  The  disturbances  of  memory  are  much  more  important, 
for  he  forgets  from  one  day  to  another,  from  one  hour  to  another. 
He  remembers  only  the  most  important  facts  of  his  life,  those  that 
have  impressed  him  strongly.  For  example,  he  will  relate  the 
incident  of  the  night  of  September  3,  1894,  when  he  received  a 
blow  from  a stick  on  the  nape  of  the  neck,  and  was  shot  with  a 
revolver,  the  bullet  entering  the  right  temporo-parietal  region  and 
being  extracted  from  the  left  frontal  protuberance  ; but  he  himself 
declares  that  he  cannot  execute  the  simplest  orders.  For  instance, 
he  left  the  house  to  go  a message  for  an  aunt,  but  he  was  hardly  in 
the  street  before  he  had  forgotten  everything,  and  he  did  not  actually 
know  where  he  was.  When  he  did  reach  his  destination  he  had  no 
idea  what  he  was  to  say  or  what  to  do.  Many  times  he  never  ■ 
reached  his  destination,  and  after  wandering  about  for  a longer  or  i 
shorter  time,  returned  home  like  a person  bewildered. 

His  conduct  appears  to  be  correct,  but  his  eye  is  fearful  and  his  ■ 
look  inexpressive-.  Simple  perceptions  are  readily  realized,  while  • 
the  more  complex  are  slowly,  and  sometimes  not  at  all,  effected. 
He  has  great  difficulty  in  localizing  himself  in  time,  either  present 
or  past.  His  slow  and  poor  ideation  is  clearly  a result  of  his  enor-  ; 
mous  difficulty  of  evocation.  He  complains  of  constant  pains  in  { 
the  head,  and  often,  as  he  himself  declares,  he  sees  stars  passing  | 
before  his  eyes.  Little  things  appear  to  him  magnified  and  trans-  j 
formed,  and  he  is  conscious  of  this  state  of  things.  He  has  no  true  ^ 
will,  but  rather  whims,  impulses,  caprices,  and  facile  reactions.  ^ 

Even  provoked  attention,  which  at  the  beginning  of  the  ex- 
amination appears  ready,  is  very  soon  exhausted.  After  the  first 
few  questions  he  falters.  His  personality  is  the  result  of  representa- 
tions, phantasms,  and  rudimentary  notions,  isolated  and  uncon- 
nected, like  the  ruins  of  columns  without  capitals  and  without 
arches.  Association  and  differentiation  of  images,  of  ideas,  and 
even  of  the  simplest  judgments,  is  either  impossible  for  him  or  can  ■ 
be  effected  only  with  the  help  of  other  persons  who  know  the  facts,  i 
and  lead  him  on  by  recalling  objects,  places,  and  persons  that  he  4, 
recognises  in  his  memory.  J| 

It  is  noteworthy  that  he  perceives  all  external  objects  and  I 


PHYSIO-PATHOLOGY  OF  MEMORY 


285 


understands  very  simple  language.  The  psychic  process,  however, 
stops  at  perception  which  does  not  provoke  that  more  or  less  exten- 
sive movement  of  images  that  is  found  in  the  sane  individual,  and 
that  he  himself  had,  prior  to  receiving  the  wound  on  the  head  ; per- 
ception remains  isolated,  or  evocation  is  restricted  solely  to  the 
com.plementary  images  that  integrate  the  consciousness  of  an  object, 
permitting  it  to  be  recognised  on  every  occasion.  Further,  he  lacks 
spontaneous  evocation  and  especially  voluntary  evocation.  He 
cannot  reply  circumstantially,  determining  time  and  place,  what- 
ever be  the  matter  about  which  he  is  questioned. 

This  patient  has  remained  a long  tim,e  in  the  clinique  in  the 
condition  described,  though  he  has  improved  a little  through  re- 
education. The  fact  that  he  recognised  objects  and  understood 
words  proved  that  im,ages  existed  and  were  reproducible,  and  that  his 
defect  was  in  the  evocative  power  sustained  by  the  process  of  syn- 
thesis, which  is  a function  of  the  frontal  lobe.  Through  this  defect 
of  synthesis  his  m.emory  power  was  weakened. 

Of  partial  disorders  of  memory  some  are  open  to  psycho- 
physiological  examdnation, while  others  are  still  wrapped  in  obscurity 
as  regards  their  origin  and  m,echanism.  Among  the  former  the 
most  notable  exam.ple  is  supplied  by  the  dysphasic  disorders. 
If,  on  the  one  hand,  these  have  furnished  the  m,ost  irrefragable 
proof  of  functional  localization  on  the  cortex  of  the  brain,  on  the 
other  hand,  they  offer  examples  of  the  m,ost  classical  partial  defects 
of  memory. 

If  we  admit  it  to  be  a dem,onstrated  fact  that  the  neuropsychic 
factors  of  language  are  localized  in  various  and  sufficiently  well- 
defined  areas  of  the  cortex,  and  if  we  agree  that  the  physiological 
signification  of  these  areas  lies  in  the  formation  and  conservation 
of  verbal  images,  sensory  and  motor,  it  is  easy  to  understand  that 
similar  or  analogous  images  coming  from  outside  awaken  those 
previously  formed,  and  are  therefore  recognised  them,selves.  These 
in  their  turn  awaken  correlative  m.otor  images,  which  are  repro- 
duced in  the  spoken  or  written  word.  It  follows  that  the  destruc- 
tion or  the  arrest  of  function  of  one  of  these  centres  must  of 
necessity  cause  im.possibility  or  incapacity  of  mnemonic  repro- 
duction of  all  those  images  that  have  been  form,ed  during  the  course 
of  life  and  stored  up  in  the  centre  that  is  destroyed  or  inhibited. 
A person  who  is  affected  by  word-deafness,  through  destruction 
of  the  first  temporal  convolution  on  the  left  side,  not  only  does  not 
understand  the  speaker,  but  he  cannot  himself  speak  in  his  turn, 
because  the  centre  of  conservation  of  acoustic  verbal  images  has 
been  destroyed,  and  these  im.ages  constitute  the  m_ost  potent  sensory 
excitant  of  the  kinaesthetic  centre  of  the  spoken  word.  If  that 
same  centre  were  corcipressed  or  inhibited  by  a destructive  focus 
situated  in  its  neighbourhood  (a  condition  that  has  caused  some 


286 


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to  believe  that  there  may  be  another  centre  for  the  recollection  of 
words),  the  subject  would  understand  a speaker,  but  would  have 
lost  a greater  or  less  capital  of  mnemonic  images,  or  he  would  be 
powerless  to  evoke  them,  so  that  he  would  be  obliged  to  borrow 
others  from  without.  This  phenomenon  has  received  the  name 
of  aphasia  amnesica. 

In  like  manner,  were  a cultured  gentleman  to  suffer  a lesion  of 
the  lower  left  parietal  lobule,  he  would  afford  a surprising  example 
of  an  individual  who  has  conserved  all  his  intelligence  except  the 
co-efficient  which  is  represented  by  the  visual  graphic  images 
that  are  normally  represented  each  time  the  individual  reads,  and 
through  which  the  significance  of  the  graphic  symbols — that  is, 
of  the  written  word — is  recognised.  He  would  perhaps  lack  as 
many  words  as  were  articulated  through  the  representation  of  the 
visual  graphic  images. 

An  example  of  complete  loss  of  the  visual  verbal  patrimony 
in  a visual  subject  I give  as  follows  : 

A lady  who  was  received  into  my  clinique  was  confused  and 
agitated.  On  observing  her  attentively,  I was  able  to  ascertain 
that  her  confusion  and  agitation  were  due  especially  to  the  fact  that 
she  was  affected  by  a certain  degree  of  word-deafness.  She  under- 
stood only  a few  of  the  words  that  were  addressed  to  her.  It 
appeared  to  be  a typical  case  of  sensory  aphasia,  with  which  was  ’ 
associated  a state  of  confusion  and  also  psycho-motor  agitation.  A ! 
more  careful  examination  brought  out  the  fact  that  the  incomplete 
word-deafness  was  associated  with  complete  word-blindness  (word-  ’ 
blindness  with  agraphia).  This  lady  had  been  a teacher.  She  = 
was  well  acquainted  not  only  with  Italian,  but  also  with  French,  ' 
and  she  taught  music.  Now,  she  had  completely  forgotten  music  ’ 
(amusia),  so  that  not  only  was  she  incapable  of  recognising  written  ; 
words  (alexia),  but  she  did  not  even  know  the  musical  notes.  Further,  ( 
she  never  spoke,  in  consequence  of  the  almost  total  loss  of  her  vocab-  | 
ulary.  She  did  not  remember  a single  name.  She  made  some  ^ 
improvement  with  regard  to  her  word-deafness,  but  she  retained  ^ 
complete  word-blindness,  with  right  homonymous  bilateral  hemian-  ^ 
opsia,  complete  agraphia,  great  poverty  of  language,  and  sometimes  . 
paraphasia. 

She  remained  in  this  state  for  more  than  a year,  and  was  the 
subject  of  demonstrations.  The  diagnosis  was  word-blindness  with 
incomplete  word-deafness,  due  to  a destructive  focus  of  the  angular 
gyrus  and  the  surrounding  zone,  extending  to  the  thalamo-occipital 
optic  radiations.  Three  months  before  her  death  she  was  seized 
by  another  fit  of  vertigo.  (Her  illness  began  with  attacks  of  vertigo 
that  overtook  her  when  she  was  in  good  general  and  mental  health,  | 
and  it  was  then  that  the  psychic  symptoms  were  first  noticed,  I 
causing  her  to  be  taken  to  the  asylum.)  After  this  second  attack  of  ■ 


PHYSIO-PATHOLOGY  OF  MEMORY 


287 


vertigo  she  had  complete  word-deafness.  She  no  longer  under- 
stood a single  word,  whilst  before  she  had  understood  several.  She 
fell  into  a state  of  absolute  indifference  and  apathy,  not  expressing 
a single  thought  or  manifesting  a desire  or  need.  She  would  no 
longer  pronounce  a word,  even  though  invited  to,  and,  in  short,  she 
presented  a state  of  complete  dementia.  Soon  afterwards  she  died. 

At  the  autopsy  I found  two  foci  on  the  external  aspect  of  the 
left  hemisphere,  one  limited  to  the  middle  and  posterior  part  of  the 
first  and  to  a small  portion  of  the  second  left  temporal  convolu- 
tion, and  the  other  on  the  left  angular  gyrus,  extending  a little  way 
into  the  marginal  convolution. 

On  the  right  hemisphere  there  was  observed  another  focus, 
perfectly  symmetrical  with  that  found  on  the  first  and  second  left 
temporal  convolutions. 

To  tell  the  truth,  as  this  was  the  case  of  an  educated  woman 
who  had  been  teaching  for  a long  time,  and  as  in  course  of  time  the 
word-deafness  appeared  to  have  improved  in  some  degree  with 
exercise,  I had  attributed  the  whole  complex  of  symptoms  to  a 
lesion  of  the  angular  gyrus.  I came  to  this  conclusion  from  the 
persistence,  with  no  sign  of  improvement,  of  all  the  symptoms  of 
word-blindness  and  of  hemiopia,  whilst  the  improvement  of  the 
word-deafness  was  progressive  ; and  from  the  probability  that  the 
dementia  might  well  arise  from  a lesion  of  the  angular  gyrus  in  a 
subject  who,  as  she  had  read  much,  must  have  utilized,  in  the 
process  of  thought,  many  more  visual  than  aural  word-images. 

Further,  there  is  the  fact  that,  owing  to  the  functional  pre- 
ponderance of  the  visual  centres  of  speech  over  the  others,  word- 
deafness  in  this  case  might  well  arise  from  the  lesion  of  the  inferior 
parietal  lobe,  instead  of  from  lesion  of  the  first  temporal  convolution. 
This  seemed  likely,  and  the  more  so  to  me,  as  I had  had  the  oppor- 
tunity of  observing  an  individual  who  had  been  a compositor,  and 
as  such  had  become  visual,  and  I had  found  that  he  showed  marked 
amnesia  of  words  along  with  his  word-blindness  (L.  Bianchi,  ‘ Con- 
tributo  alia  dottrina  delle  afasie  ottiche"  Ann.  de  NevroL,  i8gi). 
In  this  second  case,  the  hypothesis  was  probable  in  so  far  as  the 
practice  of  reading  makes  the  mnesic  evocation  of  the  visual  images 
of  words  more  ready  ; in  other  terms,  visual  memorization  is  much 
easier  than  aural  memorization.  We  may  well  agree  that  in  those 
persons  who  have  had  long  practice  in  reading,  and  who  have  learned 
much  through  reading,  the  motor  centre  of  the  whole  mechanism  of 
speech  is  not  the  aural  but  the  visual  centre,  and  this,  each  one  of 
us  may  prove  by  observation  upon  himself. 

The  differentiation  of  the  cerebral  mantle  consists  in  the  for- 
mation and  conservation  of  special  groups  of  images  of  a higher 
order.  To-day  no  one  doubts  any  longer  the  constitution  of  a 
differentiated  area  in  the  occipital-parietal  lobe  for  images  and 


288 


PSYCHIATRY 


recollections  of  places.  If  that  area  were  destroyed,  the  subject  | 
would  Jose  his  recollection  of  places,  and,  though  he  might  preserve  ’ 
his  intelligence  intact,  he  would  lack  that  small  co-efhcient  and  thus  ’ 
would  be  incapable  of  finding  his  bearings,  in  whatever  point  of  a 
city  he  might  be. 

If  we  agree  upon  the  doctrine  of  the  functional  evolution  of 
certain  cortical  zones  of  the  brain,  so  that  those  which  are  termed 
the  interlocking  zones  would  not  be  latent,  as  appears  to  be  held 
by  some  authors,  but  rather  specialized  centres  for  higher  functions 
such  as  reading  and  writing  musical  notes,  then  functional  inhibi- 
tion or  destruction  of  these  zones,  in  a brain  educated  in  music, 
will  entail,  as  a necessary  consequence,  amnesia  of  all  the  m.anifesta- 
tions  of  those  particular  functions,  and  that  constitutes  a loss  of 
one’s  specific  psychic  capital.  It  is  thus  we  explain  aural  or  visual 
amnesia  of  the  mmsical  notes  and  of  their  associations  (cases  of  Kant 
and  others). 

If  the  sensory  substrata — optical,  acoustic,  or  tactile — of  the 
images  of  objects  are  -wanting,  the  name  that  is  attached  to  the 
object  cannot  be  represented  in  memory.* 

In  these  cases  the  subject  is  unable  to  name  the  object  by  the 
aid  of  vision  alone.  He  must  reinforce  the  insufficient  optical 
representation  by  a series  of  actual  sensory  factors  furnished  by 
other  senses  (sound,  contact,  weight,  etc.). 

It  is  through  the  concourse  of  all  these  actual  images  that  the  ^ 
name  of  the  objects  is  forced  into  the  field  of  conscious  memory.  ; 

Aphasia  is  therefore  the  largest  contributor  to  the  knowledge 
of  amnesia,  and  if  we  could  make  a complete  and  particular  study  ’ 
of  it,  we  should  acquire  the  clearest  notions  of  the  mechanism  in  ; 
which  amnesia  arises  in  relation  to  the  functional  localizations  of  ' 
the  brain.  In  the  first  part  of  this  work  I have  already  summed  up 
our  ideas  about  the  group  of  syndromes  comprised  under  the  name  ; 
of  aphasia.  j 

If  the  matter  be  thoroughly  considered,  all  cases  of  aphasia  may  | 
finally  be  reduced  to  amnesia.  The  only  question  is  to  determine  ^ 
whether  the  amnesia  consists  in  the  impossibility  to  recognise,  to  I 
reproduce,  or  to  evoke,  and  in  this  last  case  whether  it  is  voluntary,  ^ 
or  associative  and  involuntary. 

I do  not  wish  to  return  here  to  the  vexed  question  already  touched 
upon  several  times  in  the  course  of  this  work,  whether  those  centres 
which  we  call  sensory  centres  are  or  are  not  centres  of  formation  and 
conservation  of  images  ; but  it  is  important  to  remember  that 
word  images  are  nothing  else  than  images  of  greater  complexity,  for 
the  reason  that  the  elementary  components  entering  into  their 
formation  are  more  numerous.  It  is  more  than  probable  that  they 

* Sec  a similar  observation  that  I made  in  Emiplegia,  1886,  reproduced 
in  my  volume  on  the  Malattie  del  cevvello,  which  is  included  in  the  Patologia 
Speciale  Medica  of  Cantani  and  Maragliano. 


PHYSIO-PATHOLOGY  OF  MEMORY 


289 


are  formed  and  conserved  in  those  cortical  regions  that  everyone 
now  recognises  as  the  zone  of  language,  in  accordance  with  a postero- 
anterior  evolutionary  process  of  the  cerebral  mantle  that  I have 
mentioned  in  the  first  part  of  this  work  (p.  160).  There  is  nothing 
to  prove  the  contrary. 

If,  therefore,  we  consider,  among  other  things,  the  incapacity 
to  evoke  a verbal  image  voluntarily,  when  there  is  an  interruption 
of  the  paths  between  the  field  of  intellect  and  the  sensory  centre  of 
words,  and  the  possibility  of  evoking  the  word  (even  when  it  is  not 
understood)  if  another  person  pronounce  it,  thus  utilizing  the  paths 
FF'  A'A  of  the  scheme  on  p.  140,  we  shall  find  in  this  simple  fact 
the  clearest  proof  that  the  image  is  conserved  where  it  is  formed,  and 
may  be  evoked  at  the  seat  of  its  formation  by  an  external  stimmlus, 
provided  the  subcortical  centripetal  paths  are  uninjured  and  the 
external  nervous  wave  reaches  its  cortical  centre  ; whilst  it  cannot 
be  evoked  from  another  cerebral  area  if  the  corresponding  trans- 
cortical paths  are  interrupted. 

Following  out  what  we  have  said  about  the  functions  of  the 
cerebral  cortex,  we  can  also  continue  here  the  hypothesis  that  all 
lesions  of  the  cortical  centres  of  language  give  rise  to  amnesia  of 
reproduction,  and  this  amnesia  will  be  complete  or  incomplete 
according  as  the  lesion  or  the  inhibition  is  extensive  or  circum- 
scribed within  the  limits  of  the  zone  of  language.  In  these  cases 
neither  the  word  spoken  by  others  nor  the  word  seen  can  be  repro- 
duced, and  spontaneous  thought  and  voluntary  conation  cannot  be 
translated  into  words,  while  the  objects  of  the  external  world  like- 
wise are  unable  to  evoke  their  respective  verbal  s5unbols.  Here  we 
must  bear  in  mind  all  those  differences  between  the  various  parts  of 
the  zone  of  language  to  which  I have  called  the  reader’s  attention 
in  the  first  part  of  this  work  (p.  139,  etc.). 

Amnesia  of  evocation  comprises  two  groups  referable  to  intel- 
lectual and  volitional  evocation,  and  to  sensory  and  involuntary 
evocation.  Int  he  first  case,  the  intellectual  field  does  not  do  its 
work.  There  is  defect  of  synthesis  and  of  directive  power,  and  in 
such  conditions  there  is  no  formation  of  nervous  waves  suitable  for 
transmission  over  determined  paths  to  definite  points  of  the  zone 
of  language  for  the  purpose  of  reproducing  correlative  verbal 
images  ; or  the  paths  of  communication  between  the  field  of  intel- 
lect and  the  sensory  centres  of  language  are  interrupted,  and  in 
that  case,  evocation  is  reduced  to  a vague  feeling  of  knowledge  and 
to  an  inefficient  evocative  effort. 

Amnesia  of  sensory  and  involuntary  evocation  corresponds  in 
most  cases  to  the  so-called  associative  aphasia  of  Pitres  and  others. 
It  may  be  reduced  to  this  fundamental  concept,  that  the  image  of 
the  object  which,  independently  of  all  voluntary  and  directive 
power,  was  previously  associated  with  the  image  of  the  word,  does 
not  reach  the  verbal  centre  owing  to  the  interruption  of  the  normal 

19 


290 


PSYCHIATRY 


paths  of  association,  and  the  word  cannot  therefore  be  reproduced  j 
either  for  internal  repetition  or  for  articulation.  To  put  it  other- 
wise, there  will  arise  a sort  of  involuntary  or  automatic  amnesia  of 
evocation,  which  is  very  different  from  that  voluntary  form  that 
we  have  just  been  speaking  of. 

If,  then,  the  elementary  images  that  ought  to  concur  from  their 
respective  centres  to  form  concrete  images  (which  images  give  us 
the  true  notion  of  the  object  and  therefore  the  proper  words)  cannot 
come  together  in  the  ideative  synthesis  because  the  associative  paths 
are  interrupted  here  and  there,  we  have  another  variety  of  disorder 
of  memory,  which  also  belongs  to  the  group  of  associative  amnesias. 

Such  defects  of  memory  may  have  various  origins,  or  they  may 
even  be  provoked  by  hypnotic  suggestions,  or  by  auto-suggestion  in 
hysterical  subjects.  Just  as  the  hypnotized  person  may  be  made  to 
forget  an  event,  a scene,  or  a word,  so  in  hysterical  subjects  certain 
centres  lose  the  capacity  to  furnish  the  product  that  would  be  given 
if  their  functions  were  properly  fulfilled.  Along  with  the  anaes- 
thesia found  in  hysterics,  due  to  diminished  dynamogenesis,  there 
is  a great  torpor  of  the  whole  mnesic  process.  In  some  of  these 
cases  the  amnesia  is  limited  to  a few  names,  or  to  some  figures,  as 
in  the  case  of  Ferrari.  Paralysis,  anaesthesia,  hysteric  amaurosis 
are  only  partial  amnesias — tombs  of  living  beings  that  the  skilful 
medical  man  can  often  lay  open  by  his  talent. 

After  what  has  been  said  in  the  first  part  of  this  work  and  in  ; 
the  beginning  of  this  chapter,  it  is  not  necessary  to  indicate  here  the 
anatomical  substratum  of  memory.  All  the  perceptive  zones  are 
centres  of  formation  and  conservation  of  their  respective  products,  r 
in  the  same  way  as  the  centres  of  psychic  synthesis  are  the  seats  of 
formation  and  conservation  of  the  particular  products  of  their 
activity.  ; 


CHAPTER  IV 


PHYSIO-PATHOLOGY  OF  IDEATION 

On  several  occasions  in  the  preceding  chapters  I have  recorded  a 
fact  that  is  of  capital  importance  for  the  study  of  thought — the 
creative  power  of  the  human  intellect.  Nature  gives  us  only  the 
raw  material,  out  of  which  the  intellect  constructs  modest  phan- 
toms of  imagination  or  the  marvellous  and  immortal  creations  of 
genius,  in  the  same  way  as,  with  other  raw  material,  man  constructs 
the  hut  of  the  savage,  the  cottage  of  the  poor  labourer,  or  the  sump- 
tuous palaces  of  the  rich  ; the  small  hamlet  or  the  magnificent 
metropolis,  where  men,  like  thoughts,  live,  associate  together,  oppose 
one  another,  separate,  act  or  remain  inactive,  grow  up,  and  die. 

With  the  continual  increase  of  sensations  received  and  of  per- 
cepts, thought  is  evolved  in  a process  of  uninterrupted  formation 
and  of  perennial  exchange,  through  which  our  notions  and  judg- 
ments assume  diverse  forms,  and  the  several  thoughts,  variously 
nourished  and  coloured,  succeed  one  another  in  the  most’  different 
combinations,  with  a tendency  to  manifest  themselves,  to  reflect 
themselves,  and  to  follow  one  another  in  the  most  widely  different 
conditions  of  time,  place,  and  manner.  There  we  have  the  true 
characteristic  of  human  thought.  There  is  no  static  element  in 
an  awakened  consciousness  ; everything  is  in  motion  there.  What- 
ever image  crosses  its  threshold  drives  out  some  other  one,  and 
may  become  the  evocative  centre  of  attraction  of  others,  as  the  star 
that  drags  behind  it  a large  number  of  minor  stars,  forming  with 
the  first  a true  constellation,  rises,  passes  its  zenith,  and  sets,  closely 
followed  by  others.  It  is  easy  to  demonstrate  that  some  satellites 
of  the  first  star  return  as  satellites  of  a second  and  of  yet  a third, 
and  the  satellite  of  one  constellation  becomes  the  centre  of  new 
formations  or  of  a new  constellation,  in  which  the  larger  star  of 
the  preceding  constellation  will  find  itself  a satellite  in  a different 
combination. 

We  cannot  conceive  of  the  intellect  in  a static  condition  beyond 
a relatively  small  interval  of  time,  as  it  is  not  possible  that  the 

291  19—2 


292 


PSYCHIATRY 


molecular  movement  should  halt  for  a single  instant  in  the  living 
organism.  Dynamism  is  the  condition  of  mental  life  as  of  organic 
life.  The  slowing  down  of  the  continual  motion  in  consciousness 
and  in  the  unconscious  is  decline  towards  death,  and  is  therefore 
a morbid  fact.  While  constellations  are  being  formed  and  organized, 
the  components  of  one  pass  into  another,  and  then  into  another,  the 
number  of  combinations  being  greater  the  simpler  they  are. 

It  is  well  to  give  an  example  : 

.In  the  representation  of  paper  we  find  some  components, 
such  as  the  white  colour,  the  tacto-muscular  images  of  thinness, 
flexibility,  and  smoothness,  which  we  meet  again  as  components  of 
very  many  other  images.  It  is  their  particular  combination  that 
characterizes  the  specific  quality  of  a concrete  image. 

In  the  fact  that  the  simple  images  enter  as  components  into  a 
great  number  of  concrete  images,  and  that  their  combinations  may 
be  multiplied  infinitely,  we  find  the  law  of  evolution  supreme. 
Every  hour,  every  day,  gives  a very  great  number  of  new  products, 
which  enter  into  combination  with  those  preceding  them,  and  in- 
crease the  thought  and,  with  the  thoughts,  the  personality.  As  new 
instruments  added  to  an  orchestra  always  render  the  music  more 
harmonious,  with  a more  complex  harmony,  and  increase  its  power 
of  aesthetic  action  on  the  mind,  giving  greater  delicacy  to  the  emo- 
tional passages,  and  rendering  the  fused  notes  less  easy  of  analysis, 
so  the  new  percepts,  combining  with  those  already  formed,  always 
give  greater  consistency  in  the  mdnd  to  that  Nature  of  which  the 
mind  is  a reflection,  and  to  the  laws  of  its  own  existence. 

The  increase  of  psychic  products  is  continuous  and  perennial,  and 
results  from  the  action  of  the  agencies  of  Nature  on  the  perceptive 
centres  ; and  the  increment  of  the  psychic  personality  is  likewise 
continuous  and  perennial,  the  clearer  being  the  differentiation  of 
the  ego  from  surrounding  Nature,  the  more  fully  the  latter  is  known  ; 
or,  what  is  really  the  same  thing,  the  greater  the  number  of  the 
perceptions  and  the  more  active  the  process  of  assimilation  and 
fusion  of  these,  for  the  formation  of  more  complex  psychic  products, 
which  synthetize  our  notion  of  the  psychical  and  social  environ- 
ment. In  this  process  we  may  recognise  the  spiritualization  of 
Nature  and  the  formation  of  the  consciousness  from  matter.  Two 
orders  of  psychic  products  are  formed  with  the  percepts — the 
aggregated  and  the  composite.  The  first  may  be  decomposed  into 
their  elements,  which  are  associated  with  one  another  in  the  most 
diverse  manner,  giving  rise  to  the  most  varied  representations  in 
consciousness. 

Although  the  second  may  be  subjected  to  the  process  of  analysis, 
as  performed,  for  example,  b}^  the  psychologist  when  he  examines 
them,  they  are  stable  compositions,  and  represent  determined 
external  facts  or  definite  relations,  being  associated  in  the  most 
diverse  manner  with  one  another  and  with  the  aggregates,  in  the 


PHYSIO-PATHOLOGY  OF  IDEATION 


293 

perennial  motion  of  conscious  and  unconscious  thought,  in  the  same 
individual  and  in  the  different  individuals  of  the  community. 

All  concrete  images  and  words  are  stable  composites  in  so  far  as 
they  express  determined  objects  and  fixed  relations.  The  concrete 
image  of  book  results  from  a certain  number  of  more  elementary 
images  that  have  undergone  a process  of  fusion.  The  frontispiece, 
the  pages,  a certain  quantity  of  sheets  of  paper,  the  degree  of  thin- 
ness and  of  smoothness,  their  numbers,  the  size  and  colour  of  the 
letters,  their  form,,  the  line  spacing,  the  particular  noise  made  by  the 
leaves  when  turning,  are  so  many  of  these  simpler  and  particular 
images  fused  together  to  give  as  a result  a more  complex  image. 
This  latter  image  is  a composite,  of  which  the  components  are 
indissociable  from  the  concrete  image  of  book.  Books  differ  in 
size,  in  quality  and  colour  of  paper,  in  binding,  in  shape  and  size 
of  letters,  in  colour  and  gilding  of  the  back,  in  the  languages  in 
which  they  are  written,  in  the  various  subject-matters,  and  in  ever 
so  many  other  particulars,  of  which  the  respective  images  have 
been  fused  in  such  a way  as  to  give  an  indecornposable  ideative  com- 
posite, which  is  the  general  idea  of  book,  and  which  differs  from  the 
concrete  image  of  book.  The  latter  is  referable  to  each  book  that 
I have  seen  or  that  has  passed  through  my  hands,  as  when  I seek  in 
my  library  a certain  volume  that  I once  turned  over,  and  in  which  I 
read  something  that  has  remained  well  impressed  on  my  memory. 
The  general  image  results  from  the  visual  image  of  a great  number 
*of  books,  from,  the  visual  images  of  their  separate  parts,  from  the 
tactile  and  tacto-muscular  images  (size,  weight)  of  the  volumes  that 
have  passed  through  my  hands,  from  the  auditory  images  received 
when  turning  them  over,  from  the  names  of  the  authors,  from  the 
particulars  of  their  contents  fixed  in  my  memory,  which  in  their  turn 
are  visual,  auditory,  and  kinaesthetic  images  of  words,  and  lastly 
from  their  conceptions.  All  this  is  fused  into  the  general  image  of 
book.  Each  book  has  general  characters  and  differential  charac- 
ters. The  latter  belong  to  the  concrete  images  as  integral  parts, 
and  through  them  each  concrete  image  is  distinguished  from  all 
others.  The  general  and  the  particular  characters  are  all  fused  in 
the  general  idea  of  book,  which  represents  a very  comprehensive 
product,  analogous,  if  we  may  take  an  example  from  chemistry,  to  a 
product  of  very  complex  atomic  constitution,  formed  by  organic 
molecules,  which  in  their  turn  are  of  complex  atomic  constitution. 

The  general  idea  is  not  referable  to  any  single  concrete  image, 
but  to  the  aggregate  of  all  those  images  that  compose  it,  and  that 
are  synthetized  in  the  word  in  which  the  general  idea  takes  its  form. 
All  the  concrete  images  from  which  this  word  results  remain  on 
the  first  plane  of  consciousness  in  larger  or  smaller  number,  and  we 
have  the  representation  mainly  of  those  that  the  memory  brings 
up  with  the  best  definition  and  colouring,  these  features  being  given 
by  the  strongest  impressions  and  those  that  have  assumed  the 


294 


PSYCHIATRY 


greatest  number  of  associative  relations.  Concrete  images,  like 
general  ideas,  have  an  assimilative  power,  strong  in  proportion  to 
the  perceptive  and  attentive  power  of  the  individual.  If  I take 
the  same  book  into  my  hands  on  several  occasions,  each  time  I shall 
note  som,e  feature  that  had  escaped  my  former  observation,  and  I 
shall  learn  something  else  contained  in  the  book  that  I did  not  know 
before.  All  these  secondary  images  and  notions  enter  into  the 
concrete  image  of  the  single  volume  in  such  fashion  that,  when  I 
reproduce  the  image  of  a given  book,  I can  represent  to  myself  a 
host  of  other  images  and  of  recollections  referable  exclusively  to  that 
of  the  particular  book,  the  number  of  these  varying  more  or  less 
with  each  concrete  im,age.  All  these  secondary  images  are  non- 
essential  to  the  constitution  of  the  concrete  image  of  the  book,  but 
they  are  secondary  parts,  attending  in  various  numbers  on  each 
concrete  image.  It  is  evident  that  the  concrete  image  that  the 
illiterate  man,  or  the  man  of  little  culture,  has  of  a book  is  very 
different  from  that  the  student  has  of  each  volume  in  his  library. 
Every  image  has  an  assimilative  power,  in  virtue  of  which  it  in- 
tegrates itself  with  assimilable  elements  of  the  external  world. 

The  general  idea  possesses  an  equal  assimilative  power.  Each 
new  book  that  is  seen  or  read  furnishes  new  concrete  images  that 
fuse  with  all  the  others  into  a synthetic  product,  which  is  the 
general  idea  of  book.  This  general  idea  is  incremented  by  the  new 
images  and  becomes  more  complex.  Such  fusion  cannot  be  realized 
except  by  the  aid  of  the  word.  The  word  alone  possesses  the 
resuming  property  ; it  alone  is  the  cold  receiver  into  which  fall,  like 
distilled  drops,  the  new  images  that  are  to  combine  with  those  pre- 
ceding ; and  new  images  are  always  coming  as  long  as  life  lasts,  and 
in  proportion  to  the  apprehensive  power  of  the  personality.  The 
word  alone,  that  little  and  inextensible  organism,  comprehends 
them  all  and  expresses  them  in  one.  In  this  way  are  formed  our 
concepts,  which  are  inseparable  from  names.  Conceptualism  and 
nominalism  are  two  correlative  and  co  - existing  terms  for  two 
facts  that  are  indivisible,  just  as  life  and  organism  are  indivisible. 
Life  may  cease  and  the  organism,  or  rather  the  mummy  of  it,  may 
remain,  as  sometimes  the  content  of  the  concept  disappears,  leaving 
the  word,  which  is  its  corpse  ; or  the  form  may  be  moulded  by  a 
man  of  inferior  power,  without  life  and  without  content,  like  the 
pasteboard  doll  that  a child  shapes. 

Images,  however,  not  having  immediate  relations  with  time, 
transport  us  beyond  the  bounds  of  our  immediate  environment. 
This  excursion  into  consciousness,  beyond  our  immediate  and  direct 
perception,  immensely  facilitates  extension  in  the  relations  of  time 
and  space  ; and  when  objects  have  thus  reached  the  luminous 
point  in  consciousness  they  become  nuclei  for  the  formation  of  con- 
cepts, serving  as  a centre  of  attraction  and  assimilation  of  other 
images.  According  to  H.  Abit  (International  Congress  of  Psy- 


PHYSIO-PATHOLOGY  OF  IDEATION 


295 


chology,  1900),  the  mind  commences  with  a manner  of  thought  that 
is  neither  general  nor  particular,  but  generic.  The  perception  that 
reflects  the  individual  and  the  conception  that  reflects  the  genus 
are  two  formulae,  like  two  branches  that  start  in  parallel  directions 
from  the  same  trunk.  The  percept  does  not  precede  the  concept, 
but  is  contemporary  with  it.* 

The  concrete  images  that  enter  into  the  composition  of  concepts 
are  duplicates.  These  duplicates  in  concepts  have  no  proper  life  of 
their  own,  but  are  maintained  in  activity  by  the  centre  of  their  for- 
mation. If  this  centre  is  destroyed  they  lose  their  vitality  and  die 
like  the  originals,  and  the  concept  loses  one  category  of  its  com- 
ponents, and  is  atrophied.  In  the  same  way  as  the  concrete  images 
of  separate  objects  are  maintained  active  by  the  elementary  images 
from  which  they  result  (see  Part  I.),  the  more  complex  mental  pro- 
ducts are  maintained  active  by  the  latent  life  of  all  the  concrete 
images  by  which  they  have  been  formed. 

When  the  number  and  the  vitality  of  these  diminishes,  or  when 
they  die,  the  number,  comprehensiveness  and  extension  of  the  con- 
cepts diminish,  or  these  concepts  lose  their  active  qualities  and  pass 
away.  The  clinique  furnishes  numerous  examples  in  confirmation 
of  this,  of  which  I cite  one.  A blind  man  (amblyopic)  was  received 
into  my  clinique,  suffering  from  dementia.  He  showed  no  somatic 
disorder,  but  was  somewhat  deranged  and  very  much  impoverished 
mentally,  so  much  so  that  he  would  reply  only  to  some  questions, 
and  then  after  considerable  pauses.  He  took  no  initiative  when  he 
perceived  that  there  were  persons  around  his  bed,  but  listened  and 
understood  what  was  said  to  him,  preserving  all  the  movements 
and  all  the  manners  of  sensibility.  At  the  autopsy  the  sole  cause  of 
the  dementia  was  found  to  be  extensive  foci  of  softening  in  both  the 
occipital  lobes.  All  the  rest  of  the  brain  was  normal.  In  this  case 
the  whole  rich  patrimony  of  visual  images  had  been  suppressed, 
and,  therefore,  the  frontal  lobes,  and  other  parts  of  the  mantle  did 
not  become  charged  with  the  tensions  necessary  for  the  representa- 
tion of  their  proper  products,  the  activity  of  these  parts  being 
conditioned  precisely  by  the  continual  influx  of  specific  waves  from 
all  the  active  parts  of  the  cerebral  mantle. 

Every  nascent  thought  is  supported  by  the  whole  retinue  with 
which  it  has  associative  relations.  It  is  like  the  speaker  of  a party 
whose  thought  is  supported  by  that  of  all  the  associates  whom  he 
represents. 

The  duplicates  of  each  image  that  enter  into  the  constitution 

* This  conception  of  Abit  is  undemonstrable.  If  to-day  man  can  no 
longer  represent  sensations,  that  is  due  to  the  complex  constitution  of  his 
nervous  system  ; but  it  is  evident,  if  we  follow  the  phylogenesis  of  the  mind, 
that  the  process  of  fusion  could  not  have  been  realized  without  the  further 
development  of  the  nervous  system.  The  concept  of  progressiveness  that 
has  been  elaborated  in  the  chapter  on  perception  is  applicable  also  to 
thought. 


296 


PSYCHIATRy 


of  concepts  have  no  self-existence.  They  live  with  the  waves  con- 
tinually transmitted  from  the  respective  perceptive  centres — that 
is  to  say,  from  the  original  images  that  are  conserved  in  them.  The 
whole  history  of  destructive  foci  of  the  sensory  centres,  of  the  zones 
of  evolution  (language),  and  of  the  associative  paths,  is  an  extended 
and  irrefragable  demonstration  of  this  law,  which  animates  and 
governs  the  whole  complicated  mechanism  of  the  intellect.  If  one 
centre  is  destroyed,  or  one  path  is  intercepted,  the  activity  of  the 
others  diminishes,  and  the  whole  intellectual  life  feels  the  effect  ; 
the  note  of  the  broken  cord  is  wanting  in  the  preform,ed  harmony 
of  the  musical  arrangement. 

In  the  continual  movement  of  images  there  prevails  the  char- 
acter of  those  that  predominate  greatly  over  the  others  in  number 
and  in  vivacity  of  representation.  Thus,  in  the  motion  and  explica- 
tion of  thought,  men  appear  rather  strongly  visual  if  visual  images 
prevail  over  others,  or  they  may  be  rather  more  aural  or  more  tacto- 
motor.  According  to  the  development  of  the  mind  thought  will 
be  more  sensory  when  there  is  a prevalence  of  concrete  im,ages,  and 
more  conceptual  when  there  is  a prevalence  in  num,ber  and  repre- 
sentative power  of  concepts. 

A child  of  eight  years,  who  reproduces  a drawing  or  a figure  ver\’ 
perfectly  on  a pavem,ent,  must  possess  in  a high  degree  the 
power  of  forming  lucid  visual  images  and  precise  associations 
between  visual  and  tacto  - motor  images,  whence  he  derives 
the  measure  and  precision  of  movement,  just  as  the  artist  I have 
already  mentioned  possessed  great  ability  in  drawing  the  exact 
outlines  of  any  figure,  running  from  some  distance  towards  his 
canvas,  and  drawing  rapid  strokes  with  marvellous  precision.  This 
was  the  case  with  Raphael  and  with  Horace  Verne t,  who  drew  from 
his  infancy,  ‘ just  as  a professor  of  belles-lettres  knows  how  to  write 
and  there  are  very  many  other  examples. 

The  type  may  be  prevalently  tacto-motor,  as  with  Konnewka, 
mentioned  by  Hirt,  who  could  cut  designs  in  paper  under  the  table, 
making  profiles  of  the  most  exact  resemblance  without  ever  looking 
at  them,  or  as  with  a great  violinist  who  has  a very  true  measure 
of  the  actual  space  on  the  finger-board  of  the  violin,  a singer  who 
measures  the  vocal  spaces  with  the  force  of  his  innervation,  or  an 
orator  who  possesses  the  precise  measure  and  the  faithful  motor 
memory  required  for  the  exact  articulation  of  each  word  and  for 
that  sympathetic  inflection  of  voice  of  which  only  the  greatest 
orators  are  masters. 

It  is  quite  clear  that  in  these  cases  there  is  never  only  one  single 
form  of  memory  at  work.  The  motor  memoiy  of  the  singer,  the 
visual  memory  of  the  painter,  the  auditory  memory  of  the  musician, 
is  alwa^^s  associated  with  memory  of  another  sense.  Visual  and 
aural  subjects  must  of  necessity  be  also  motor,  because  it  is  onl}^ 
Irom  the  strong  and  faithful  motor  memorv  that  there  can  arise 


PHYSIO-PATHOLOGY  OF  IDEATION 


297 


the  precision  of  all  the  movements  with  which  the  imaginative 
patrimon}’  of  the  various  categories  of  men  is  expressed,  and  the 
motor  memory  of  the  orator  is  one  of  the  mnesic  forms  co-ordinated 
with  the  immense  formative,  evocative,  and  reproductive  labour  of 
his  mind. 

If  it  be  the  case  that  some  writers  support  their  thought  by  the 
prevalence  of  auditory  images,  so  that  as  we  read  them  we  must 
note  the  rhythm  and  harmony  of  the  phrase  ; and  if  in  others 
visual  images  prevail,  and  we  are  at  once  aware  of  the  colours  and 
their  nuances  arranged  in  their  most  harmonious  groupings,  yet  in 
every  case  the  product  is  complex — the  images  are  fused  and 
difficultly  separable.  So  when  we  classify  men  into  visual,  auditory, 
or  tacto-motor,  we  intend  to  draw  attention  to  the  prevalence  of 
one  order  of  images  over  the  others,  of  that  order  which  holds  the 
field  of  consciousness  with  most  certainty  and  in  the  strongest  pre- 
valence, and  gives  its  own  imprint  to  the  larger  manifestations  of 
thought. 

The  history  of  art  teaches  us  that  artists,  visual-motor  or 
auditory-motor,  are  more  sensory  than  conceptual,  just  as  youth  is 
more  sensory  than  mature  age,  and  the  childhood  of  the  race  more 
so  than  the  succeeding  generations  who  have  advanced  in  thought 
and  in  action.  Conceptualism  predominates  in  maturity  and  in  a 
very  advanced  civilization,  but  art,  which  precedes  science  and 
history,  transforms  itself  later  into  historic  and  conceptual  art, 
drawing  its  life  from  advanced  thought. 

Here  the  law  of  evolution  appears  supremx  law  of  thought  and 
word,  of  content  and  form.  The  development  of  speech  indicates 
the  grand  trajectory  that  is  described  by  the  thought  of  man,  who 
distinguishes  himself  from  all  the  other  animal  species  by  his  com- 
prehension of  his  environment  and  of  the  whole  of  nature. 

In  the  sam,e  way  as,  in  the  development  of  animal  species  and 
of  the  single  individual  of  each  species,  the  cells,  in  order  to  meet 
the  different  conditions  of  existence,  assume  various  forms  and 
employ  their  intrinsic  energy  in  various  functions,  in  harmony  with 
the  functions  of  other  groups  of  cells,  thanks  to  a continuous  process 
of  differentiation,  of  distinction,  of  division  of  labour  and  of  associa- 
tion, according  to  the  successive  evolution  of  the  animal  series  and 
of  the  individual  in  each  variety,  so  in  human  language  we  find  a 
continuous  enrichment  by  new  materials,  due  to  the  development  of 
thought  and  to  the  continuous  differentiation  and  distinction  of 
objects,  of  quaJities,  of  states,  and  of  relations.  In  the  same  way 
as,  in  the  embryogenic  development  of  the  human  organism,  some 
elementary  transitional  forms  disappear,  making  way  for  elements 
more  stable  and  more  fully  adapted  to  life  in  the  struggle  with  ex- 
ternal agents,  so  the  dead  languages  and  the  languages  that  will  die, 
being  insufficient  to  fulfil  the  purpose  of  their  existence  in  the  new 
conditions  of  intellectual  life  that  come  with  the  revolutions  of  society, 


298 


PSYCHIATRY 


pass  away  like  the  transitional  tissues  ; and,  like  those  tissues,  they 
never  return  to  life,  but  lend  their  elements  to  the  growth  of  the 
languages  that  succeed  them. 

Of  the  genealogy  of,  and  the  immense  development  attained  and 
to  be  attained  by,  speech  in  the  succession  of  ages,  we  find  the  embry- 
ology in  philology  and  linguistics.  On  the  same  analogy,  the  study 
of  the  development  of  language  in  the  infant  offers  a faint  reflection 
(although  the  conditions  are  very  different,  owing  to  heredity)  of  the 
development  of  human  language  ; and  on  the  other  hand,  anatomy, 
physiology,  and  the  pathology  of  the  nervous  system  have  brought 
to  light  a very  great  number  of  facts  which  harmonize  the  evolu- 
tionary law  of  language  with  that  of  the  organs  of  which  language 
is  a functional  manifestation — mainly  the  cerebral  mantle  (see 
Part  L). 

That  language  is  derived  from  a small  number  of  sounds  more  or 
less  articulate  and  distinct  is,  one  might  say,  proved  by  the  docu- 
ments we  have,  dating  back  to  a sufficiently  early  period  of  human 
development. 

The  radical  monosyllables,  on  which  affixes,  infixes,  and  prefixes 
have  made  such  numerous  modifications,  enriching  our  vocabulary 
by  an  extraordinary  number  of  words,  are  much  later  than  other 
sounds.  They,  or  their  derivatives,  did  not  begin  to  signify  precise 
objects  until  very  late,  and  the  abstract  sense  that  Max  Muller 
attributed  to  them  they  acquired  only  by  passing  through  the  verbal 
form.  Thus,  sarse,  which  was  the  name  of  the  serpent,  before  it 
signified  strisciare — to  glide — was  probably  a concrete  name,  and 
had  its  origin  in  the  imitation  of  the  hissing  of  the  serpent,  or  of  the 
noise  that  it  produces  when  gliding  over  the  grass. 

To-day  no  one  contests  the  doctrine  of  the  slow  evolution 
and  prodigious  antiquity  of  man,  the  infinitely  slow  evolution  of 
language  and  of  the  human  intelligence. 

Who  can  say  what  was  the  verbal  equipment  of  man  in  the 
palaeolithic  period,  which  extends  from  240,000,  or,  at  least,  from 
160,000  dovvm  to  60,000  years  ago,  or  what  it  was  in  the  mesolithic 
epoch,  or  what  was  the  equipment  of  man  in  the  neolithic  age,  which 
commenced  20,000  years  ago  ? (Woodruff,  'An  Anthropological 
Study  of  the  Small  Brain  of  the  Civilized  Man  and  its  Evolution,’ 
Amev.  Journ.  of  Insan.,  1901). 

It  is  known  that  the  cuneiform  inscriptions  of  Persia  contain  not 
more  than  379  words. 

The  learned  men  of  ancient  Egypt,  as  far  as  we  can  ascertain 
from  the  hieroglyphics,  appear  to  have  had  at  their  disposal  not 
more  than  658  words  (Max  Muller). 

The  radicals — and  that  is  as  much  as  to  say  the  linguistic  patri- 
mony of  primitive  peoples — number  no  more  than  400  to  500. 

In  a more  recent  publication  (the  Monist,  1891)  the  same  author 
insists  on  the  statement  that  radicals  are  about  800  in  number, 


PHYSIO-PATHOLOGY  OF  IDEATION 


299 


but  as  many  of  these  have  the  same  meaning,  and  might  be  omitted 
from  the  calculation  of  roots  with  special  meanings,  the  number 
could  be  reduced  as  low  as  121.  That  small  number  of  roots  has 
increased  in  arithmetical  progression. 

The  Old  Testament  contains  5,642  words,  and  Shakespeare’s 
plays  not  fewer  than  15,000  ; Robertson  and  Webster’s  Dictionary 
contains  43,566  words,  while  the  recent  editions  of  Webster  have 
70,000,  and  Fluegel’s  Dictionary  94,464  (Max  Muller,  ‘ Lectures 
on  the  Science  of  Languages,’  p.  268  et  seq.).  The  number  of  English 
root-words  is  about  461,  while  the  sum  total  of  English  words  has 
reached  about  250,000  (Max  Muller,  the  Monist,  1891). 

It  is  sufficient  to  follow  the  development  of  one  root  to  acquire 
an  idea  of  the  marvellous  way  in  which  the  magnificent  tree  of 
language  has  increased  in  new  branches. 

Take  the  root  spac,  of  very  vague,  general,  and  involved  significa- 
tion, and  we  see  that  it  has  given  : 

Spas  (Sanscrit),  to  see,  examine. 

Spek  (Greek)  became  skep  by  a common  literal  transposition. 

Specio  (Latin). 

Spehom  (Old  German),  to  see. 

The  Sanscrit  spas  has  given  : 

Spas,  guardian. 

Spashta,  manifest. 

Spasa,  spy. 

From  the  Greek  skep  are  derived  : 

Skeptomai,  I observe. 

Skepticos,  inquirer. 

Skopos,  a thing  sought. 

Episkopos,  examiner. 

From  the  Latin  specio  we  have  the  noun  species — what  is  seen. 
The  last  word  was  adopted  first  for  movable,  useful  objects,  then  for 
aromas,  which  were  considered  as  things  useful  to  life,  whence  the 
French  espece  and  its  derivatives  epices,  epicier,  and  the  Italian 
spezie,  speziale,  spezieria,  and  so  on. 

From  the  Greek  episkopos  is  derived  the  Latin  episcopus. 

This  word,  passing  through  the  barbarous  language  of  the 
Franks,  and  as  a result  of  a syllabic  contraction  due  to  selection, 
economy  of  effort,  etc.,  became  in  French  episc.  The  change  of  p 
into  V is  frequent  in  the  words  that  pass  into  French  from  Latin— 
for  example,  recipere,  recevoir  ; sapere,  savoir,  etc.  In  this  way 
episc  became  evisc.  As  a consequence  of  the  frequent  change  of  f 
into  e among  the  lower  people  at  Rome,  the  word  becomes  eves  or‘ 
evesque  in  French,  where  it  further  suffers  the  loss  of  the  5 and  takes 
the  form,  eveque  (bishop). 


300 


PSYCHIATRY 


One  other  ramification  (and  here  I mention  only  the  main 
stems). 

From  the  Sanscrit  spasa,  spy,  there  are  derived  : 

The  Old  German  speha,  spy  ; 

The  English  spy  ; 

The  French  espie,  spy  ; 

The  French  espion,  spy. 

As  man  recognises  new  objects  and  new  qualities,  new  facts,  new 
states,  and  new  relations,  owing  to  the  evolution  of  the  perceptive 
faculty  and  the  power  of  attention,  he  has  to  find  expression  for  all 
these.  His  ideas  are  continually  being  increased  with  new  words 
derived  from  the  old  ones,  in  the  very  same  way  as  the  new  ideas 
are  derived  from  the  old. 

The  growth  of  arts  and  sciences,  the  increase  of  intercourse 
between  distant  peoples,  literary  genius,  brevity  and  euphony  (the 
cause  of  selection),  and  syllabic  corruption  (M.  Muller),  have  some- 
times modified  words  so  far  as  to  make  them  lose  all  trace  of  their 
origin,  especially  in  the  labyrinth  of  the  dialects  ; nevertheless  we 
can  trace  the  general  law. 

With  our  knowledge  of  the  development  of  language  in  infants 
and  from  the  analogy  between  the  laws  governing  this  and  the 
development  of  the  language  of  early  humanity  (Darwin,  Vierordt, 
Preyer,  Kussmaul,  Taine,  Schultz,  Tracy,  and  Paola  Lombroso), 
we  shall  be  convinced  that  the  first  elements,  like  the  germs 
of  future  language  in  the  new-born  infant,  are  indistinct  sounds 
approximating  more  or  less  to  the  sounds  of  a and  e,  the  former 
expressing  pleasurable  sensations,  the  latter  disagreeable,  although 
these  are  more  or  less  indistinct. 

Vocalization  is  the  expression  of  emotion,  of  indistinct  sensation, 
not  of  the  idea.  The  vocal  mechanism  is  the  first  to  develop  in  the 
infant.  In  the  emission  of  the  various  sounds,  a is  simpler  than  e, 
which  calls  forth  the  first  movements  of  the  tongue,  these  not  being 
required  to  emit  the  sound  a. 

The  first  labial  sounds  of  m and  b,  in  combination  with  vowels 
in  the  form  of  syllables,  are  quite  without  symbolic  signification, 
or  they  are  the  expression  of  the  imitative  faculty,  and  in  satisfying 
that  faculty  the  infant  derives  pleasure  from  the  tactile  effect  as 
well  as  from  the  acoustic — for  instance,  in  the  syllables  mam,  amm, 
nl,  ml,  etc. 

The  distinction  between  the  ego  and  the  external  world  becomes 
traceable  at  the  end  of  the  first  year,  when  the  infant  emits  its  first 
articulate  sounds.  Even  at  two  years,  I and  you  are  not  distin- 
guished and  localized.  The  infant  daughter  of  Ferri  said  io  (I)  for 
the  first  time  at  twent}^-six  months,  and  Prej^er’s  infant  son  did  not 
ju'operly  distinguish  I from  you  at  thirt3"-one  months.  The  intel- 


PHYSIO-PATHOLOGY  OF  IDEATION 


301 


lectual  and  cerebral  development  of  the  infant  does  not  admit  of 
polysyllables,  but  only  of  monosyllables,  or  of  a syllabic  combination 
less  complicated  than  the  real  word  that  the  infant  intends  to  pro- 
nounce. It  has  already  the  image  of  the  object  and  the  acoustic 
image  of  the  word,  but  not  the  motor  co-ordination  required  to  ex- 
press it.  very  intelligent  infant  girl  said  000  and  afterwards 
nooo  for  sonno  (sleep)  whenever  she  wanted  to  go  to  bed.  Instead 
of  acqua  (water),  infants  say  aa.  Sometimes  they  pronounce  only 
two  syllables  for  a word  of  three  or  four.  One  of  my  children  used 
to  pronounce  pova  instead  of  portogallo,  and  infants  mentioned  by 
Taine  used  to  say  cold  for  chocolat. 

What  we  learn  from  the  examination  of  the  documents  of  the 
first  language  of  men,  the  primitive  language  of  roots,  is  its  real 
likeness  to  the  language  of  infants,  which  has,  among  other  peculi- 
arities, its  onomatopoeia  and  its  elementary  syllabic  structure  ; 
for  the  infant  always  uses  a smaller  number  of  sounds,  saying  ban 
instead  of  hlanc,  omama  instead  of  grossmamma  (Schultz). 

There  is  a want  of  precision  in  each  particular  sound,  so  that  a 
becomes  ai,  au,  iau,  etc.,  while  the  consonants  are  often  softened, 
h being  said  for  p,  soft  s for  c,  s for  2:,  th  for  v,  etc.  Some  sounds  are 
put  for  others,  as  tloix  for  croix  (Sikorsky). 

When  infants  have  become  able  to  pronounce  sounds  separately 
they  are  still  incapable  of  co-ordinating  these  to  make  a word  of 
them.  They  may  pronounce  quite  well  ca-mi-na  separately,  but 
some  time  is  still  required  before  they  can  put  thes2  syllables  together 
to  make  camminare  ; they  say  either  nannd  or  mina. 

All  these  peculiarities  of  infantile  language  confirm  the  doctrine 
of  Taine  that,  in  the  infant,  sounds  are  elaborated  by  a constant 
metamorphosis  of  the  simplest  elementary  articulatory  movements.* 

Much  more  significant  is  the  fact  that  the  words  pronounced  by 
the  infant,  generally  neologisms  or  onomatopoetic  formations,  serve 
to  indicate  a number  of  objects  and  of  relations.  Preyer’s  infant 
meant  to  express  by  the  word  atta,  I wish  to  go,  it  is  gone,  it  is  not 
there,  it  is  no  longer  there,  there  is  nothing  there,  there  is  nobody 

* Taine  and  Schultz  have  given  a physiological  interpretation  of  the 
metamorphosis  of  the  various  articulate  sounds  made  by  infants.  From 
their  observations  they  have  deduced  the  law  that  there  is  progression  from 
the  simpler  movement  to  the  more  complex,  and  articulatory  motions  are 
first  realized  through  those  organs  in  which  the  tactile  sense  is  most  developed. 
It  is  for  this  reason  that  infants  first  pronounce  the  labials  and  the  dentals 
m,  b,  p,  t,  s,  and  do  not  pronounce  k,  or  the  Italian  ch  and  j until  quite  late. 
In  the  first  place,  this  last  letter  requires  a greater  expenditure  ot  muscular 
effort  (Schultz)  ; in  the  second  place,  it  requires  a much  more  complex 
co-ordination  of  movements  than  the  infant  is  capable  of  ; finally  the  infant 
employs  the  exquisite  tactile  as  well  as  the  muscular  sensibility  of  the  lips 
and  tongue  in  pronouncing  the  labials  and  dentals,  while  to  pronounce  the 
palatals,  as  the  skin  and  the  vault  of  the  palate  have  little  tactile  sensibility, 
the  different  palatal  position  of  the  tongue  can  be  guided  by  the  muscular 
sensibilitv  alone. 


302 


PSYCHIATRY 


there,  it  is  empty,  etc.  These  appear  to  be  the  word-medals  of 
P.  Lombroso. 

It  is  probable  that  the  monosyllables  and  the  onomatopoetic 
neologisms  of  infants  are  the  correlatives  of  the  roots  of  a very  remote 
epoch  in  the  history  of  humanity.  The  predominance  of  vowels  in 
the  language  of  infants  has  its  counterpart  in  the  predominance  of 
vowels  in  many  primitive  languages.  It  is  very  probable  that  the 
man  of  the  palaeolithic  age,  and  even  of  the  neolithic  age,  had  no 
other  language  than  that  of  gestures  and  simple  vowel-sounds 
or  interjections  associated  with  some  consonant,  just  as  is  the  case 
with  certain  animals.  Later  on  there  were  formed  monosyllables, 
and  for  a long  time  these  had  various  meanings,  dependent  perhaps 
on  their  arrangem,ent  in  the  phrase . As  Curtius  has  proved  for  Greek, 
and  Schleicher,  Grimm,  Schlegel,  D’Ascoli,  Muller,  and  others  for 
Sanscrit  and  the  other  tongues,  all  these  languages  have  passed 
through  a period  of  roots,  which  generally  expressed  em,pirical 
sensory  impressions.  Even  to-day,  in  Africa  and  in  Asia,  we  find 
rudimentary  languages,  m,onosyllabic  and  com,parable  to  the 
chattering  of  birds  (Muller).  The  Vedas  of  Ceylon  have  a language 
composed  chiefly  of  guttural  sounds,  in  which  it  is  difflcult  to  perceive 
any  true  articulations  (Emerson,  Tennent). 

Hahn  and  Bradley  cam.e  to  the  same  conclusion  about  the 
language  of  som_e  Hottentots  and  that  of  an  Australian  tribe,  finding 
in  these  nothing  but  monosyllabic  cries.  In  the  language  of  Hawaii, 
for  example,  we  find  huiaioni,  to  testify.  It  is  supposed,  and  much 
evidence  supports  the  hypothesis,  that  as  words  progressed,  some 
slight  articulations  became  stronger,  and  that  the  less  the  total  t 
number  of  consonants,  the  older  and  less  fully  evolved  is  the  language.  ' 
As  with  the  development  of  the  language  of  the  infant,  so,  in  certain 
peoples,  indistinct  sounds  would  become  distinct  sounds  as  these 
passed  from  generation  to  generation.  In  all  the  dialects  of  Poly- 
nesia, according  to  Hale,  we  find  no  distinction  made  between  the 
sounds  h and  p,  d and  t,  g and  k,  I and  r.  The  Sanscrit  word  gharma  \ 
(heat)  becom.es  thermos  in  Greek,  the  aspirated  guttural  of  the  first  i 
having  turned  into  the  aspirated  dental  of  the  second,  for  the  very 
plausible  reason,  advanced  by  Max  Muller,  that  the  phonetic  diver- 
sity is  to  be  attributed  to  a previous  state  of  the  language  in  which 
the  two  or  three  m.ain  points  of  contact  were  not  yet  definitely 
separated  one  from  another,  as  happens  in  the  Polynesian  dialects 
and  in  the  speech  of  the  infant. 

When  the  infant  has  learned  to  pronounce  words  properly,  his 
stock  of  words,  like  his  stock  of  ideas,  is  very  poor,  and  these  few 
words  have  very  general  meanings.  For  example,  for  a certain 
time  he  applies  the  word  papa  to  all  the  men  he  sees,  because  he 
does  not  yet  know  the  difference  between  his  father  and  other  men. 
This  was  probably  the  case  with  the  roots  when  they  were  words  of 
a living  language,  and  it  is  so  to-day  also  with  certain  peoples 


PHYSIO-PATHOLOGY  OF  IDEATION 


303 


whose  intelligence  and  culture  have  still  remained  at  a very  low 
stage. 

The  large  modern  stock  of  words  has  been  acquired,  as  it  is 
acquired  bv  the  infant,  through  a continuous  process  of  differentia- 
tion, and  therefore  by  the  accumulation  and  the  harmmnic  arrange- 
ment of  new  ideas  and  new  concepts  derived  from,  the  first.  The 
difference  is  that  in  the  infant  of  to-day  all  the  organic  conditions 
indispensable  to  intelligence  and  to  modern  language  are  performed 
by  atavism,  whilst  in  the  very  long  prehistoric  life  of  humanity 
those  conditions  had  to  come  about  through  a slow  evolution, 
determ,ined  by  stim,uli  from,  the  external  world  in  the  broadest  sense 
of  the  word. 

The  knowledge  that  we  have  of  the  evolution  of  the  sense  of 
colour  m,ay  serve  for  all  the  other  senses,  although  our  evidence  as 
regards  the  latter  is  much  restricted. 

We  cannot  put  ourselves  in  a position  to  consider  the  psychic 
condition  of  primitive  peoples,  just  as  we  are  unable  to  penetrate 
thoroughly  the  psychic  condition  of  infants,  because  we  feel,  per- 
ceive, and  judge  quite  differently  from  the  infant  ; in  the  same 
way  we  cannot  feel  the  harm,onies  of  a concert  or  the  beauties  of  a 
painting  as  an  artist  perceives  them.  As  a matter  of  fact,  green, 
blue,  sky-blue,  violet,  were  all  included  in,  and  confused  with,  black. 
Etym,ologically,  blue  and  the  German  hlau  are  derived  from  black. 
The  Chinese  hiuan,  which  to-day  m,eans  sky-blue,  originally  meant 
black,  and  the  word  nil,  which  now  signifies  blue  in  Persian,  is  derived 
from,  the  Nile  or  Black  River  (Bucke,  ‘ The  Growth  of  the  Intellect,’ 
American  Journal  of  Insanity,  July,  1882). 

It  appears,  therefore,  that  language  has  had  a development 
parallel  with  that  of  the  human  senses  and  intellect,  from,  its  first 
stage  of  m,ore  or  less  em,otive  vowel-sounds.  The  m.echanism  of 
articulation  developed  later.  In  the  m,onosyllables  we  have,  as  in 
the  germ,,  the  first  elem,ents  of  the  future  articulated  language. 
Languages  have  been  constantly  enriched  by  new  words,  and  they 
have  thrown  off  the  old  elem,ents  of  expression  that  are  no  longer 
adapted  to  perfected  m,odes  of  im,pression  and  to  new  conditions 
of  existence.  Finally,  in  the  developm,ent  of  the  language  of  the 
infant  (ontogenesis)  we  can  trace,  reproduced  as  it  were,  the  pro- 
cess of  development  of  the  language  of  man  (phylogenesis). 

Language  and  thought,  in  my  opinion,  have  grown  parallel  with 
one  another.  They  are  two  aspects  of  the  sam,e  fact,  and  are 
inseparable,  at  least  in  so  far  as  refers  to  concepts.  The  Greek 
word  ‘ logos  ’ had  the  double  signification  of  ‘ word  ’ and  ‘ thought,’ 
and  anyone  may  convince  himself  that  ‘ Logos  ’ cannot  exist  without 
‘ logos  ’ (Max  Muller).  From,  the  example  cited  we  may  easily 
argue  the  distant  relationship  of  the  abstract  words  ‘ spectacle  ’ 
or  ‘ respectability  ’ with  the  root  ‘ spas,’  through  the  medium  of  a 
certain  num,ber  of  infixes  and  suffixes  ; and  anyone  may  convince 


304 


PSYCHIA  TRY 


himself  that  the  words  from  which  they  are  derived  had  a concrete 
meaning  resembling  the  sense  in  which  the  word  ‘ scopos  ’ was  used. 
When,  by  a continuous  process  of  association  of  concrete  images 
and  of  relations,  we  arrive  at  abstractions  such  as  those  expressed 
by  the  words  ‘ spectacle  ’ and  ‘ respectability,’  the  thought  that 
they  contain  cannot  be  represented  except  by  these  particular  words. 
We  can  imagine  to  ourselves  a visible  object,  or  several  things 
together,  that  we  have  seen  and  that  have  moved  us,  but  all  these 
images  together  are  not  the  abstract  concept  of  ‘ spectacle.’  This 
concept  exists  only  by  the  fusion  of  so  many  things  and  so  many 
relations  between  the  visible  world  and  the  ego  in  the  word 
‘ spectacle.’  Though  water  is  formed  by  the  combination  of  hydrogen 
with  oxygen,  it  is  not,  however,  the  same  thing  as  hydrogen  and 
oxygen  ; water  is  water,  and  it  exists  only  by  its  own  intrinsic 
qualities,  in  the  same  way  as  the  word  ‘ respectability  ’ exists  only 
by  its  constitution  and  by  its  content  coalescing  with  its  form. 
This  word  can  signify  nothing  concrete,  no  single  respectable  person 
or  thing,  nothing  that  falls  under  our  senses,  and  therefore  it  cannot 
awaken  the  image  of  any  percept,  except  the  phono-articulate 
symbol. 

The  word  ‘ matter,’  to  make  use  of  an  example  adduced  in  a 
recent  work  of  Max  Muller,  expresses  something  which  is  not  an 
object.  ‘ Matter  ’ per  se  does  not  exist,  just  as  ‘ spectacle  ’ does  not 
exist,  except  through  the  word  which  synthetizes  all  the  images  of 
an  infinity  of  things  comprised  in  matter. 

The  pathology  of  language  has  furnished  the  most  irrefragable 
proofs  that  concept  and  word  are  coalescent  and  inseparable,  in 
the  sense  that  the  disappearance  of  the  word  destroys  the  compre- 
hensive power  of  the  content  of  the  concept.  If  I lose  the  word 
‘ laboratory  ’ I can  represent  to  myself,  one  by  one,  the  concrete 
images  of  places  and  of  apparatus  belonging  to  a scientific  institu- 
tion, of  persons  and  of  investigations,  but  I have  no  longer  the 
synthesis  of  the  whole.  This  idea  was  clearly  expressed  by  myself 
many  years  ago  (1887),  though  not  then  new,  and  it  coincides  with 
the  conclusions  reached  by  Heinrich  Gomperz  in  an  interesting 
pamphlet  (Zur  Psychologie  der  Logischen  Grundthatsachen,  Leipzig 
and  Vienna,  1897).  If  we  could  suppose  a man  of  perfect 
understanding  deprived  of  speech,  we  might  imagine,  according  to 
this  author,  that  he  would  be  capable  'of  perception  and  of  repro- 
duction, of  attention  to  resemblances  and  differences  of  things,  of 
analysis  of  complex  images,  resolving  them  into  more  simple  ones, 
and  of  that  form  of  thought  which  we  call  imaginative  ; but  he 
would  be  incapable  of  the  fusion  of  ideas  in^o  general  ideas,  and  he 
would  be  unable  to  form  propositions  or  chains  of  reasoning. 

In  the  evolution  of  thought,  therefore,  the  formation  of  general 
ideas  by  synthesis  is  conditional  upon  the  formation  of  the  word, 
with  this  difference — that  whilst  in  primitive  speech,  as  in  the  speech 


PHYSIO-PATHOLOGY  OF  IDEATION 


305 


of  the  infant,  every  word  designates  objects  that  might  be  confused, 
in  languages  that  have  undergone  an  evolution  the  abstract  or 
general  terms  designate  a number  of  particular  objects  that  have 
some  features  in  common,  or  certain  relations  with  each  other, 
being  what  Gomperz  calls  ‘ sensible  correlatives  of  the  idea.’ 

The  states  of  profound  dementia  consequent  on  the  formation 
of  a small  destructive  focus  in  the  first  temporal  convolution  on  the 
left  side,  or  even  only  in  the  angular  gyrus  in  visual  subjects,  in- 
ducing verbal  ammesia  (Bianchi,  ' Rivista  sperimentale  di  freniatria,^ 
1887,  and  ' Dotty ina  delV  afasia  rispetto  alia  intelligenza  ed  alia 
capacita  giuridica  ’ — II  Policlinico,  T894),  offer  an  experimental 
solution  of  the  vexed  question — discussed  with  varying  fortunes  by 
Locke,  Spencer,  Romanes,  and  Max  Muller — whether  language  is 
absolutely  necessary  to  the  formation  and  manifestation  of  the  in- 
telligence. 

In  the  course  of  abstract  thought,  however,  it  may  be  stated 
that  some  particular  individuals  (concrete  images)  are  recalled  as 
sensible  representatives  of  the  whole  group,  for  if  I speak  of  cavalry 
I should  have  the  representation  of  some  soldier  or  officer  on  horse- 
back, or  of  some  scene  that  has  passed  before  me  ; or  new  associa- 
tions of  a superior  order  will  be  formed  between  the  abstract  and 
general  terms,  permitting  of  a succession  of  words  without  any 
representation  of  sensible  images  denoted  by  those  words.  In  this 
high  form,  thought  resembles  an  operation  of  algebra.  Such  a 
form  of  thought  is  most  frequently  solitary,  whilst  in  our  communica- 
tions with  others  sensible  images  always  intervene,  and  the  more  so 
that  in  these  communications,  especially  if  they  are  descriptive, 
the  speaker  always  proceeds  to  the  analysis  of  complex  images. 

From  what  has  been  said  it  is  easy  to  argue  that  the  whole 
mental  structure  rests  upon  the  law  of  association.  Aggregations 
and  combinations  (the  fusions  of  Wundt)  are  not  possible  except 
through  the  associative  power  of  all  the  psychic  formations,  from 
the  most  simple  to  the  most  complex,  and  through  the  anatomical 
substratum  which  supplies  the  organic  and  mechanical  conditions 
necessary  to  psychic  action,  as  we  have  hitherto  been  considering  it. 

Association  consists  in  the  connection  that  is  established 
between  ideas,  emotions  (Scripture),  and  movements.  These  con- 
nections exist  amongst  the  whole  patrimony  of  images  corresponding 
to  objects  external  to  ourselves  (James)  and  amongst  all  the  forms 
of  reaction  of  the  ego. 

Two  forms  of  association  are  generally  known  : association 
through  resemblance,  and  association  through  contiguity,  or,  accord- 
ing to  Wundt,  intrinsic  association  and  extrinsic  association.  In- 
trinsic association  corresponds  to  that  founded  on  resemblance, 
extrinsic  to  that  dependent  on  contiguity.  If  the  physiognomy  of 
one  person  resembles  that  of  another  person  whom  I know,  so  that 

20 


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PSYCHIATRY 


a chance  meeting  with  the  first  at  once  calls  up  the  image  of  the 
second,  in  such  a case  the  bonds  of  association  are  close,  some 
elements  of  the  two  personalities  coincide,  and  the  association  is 
intrinsic. 

If,  on  the  other  hand,  when  I meet  a person  whom  I have  seen 
on  a former  occasion  in  som,e  other  place,  I have  a representation 
also  of  the  locality  or  the  image  of  another  person  who  chanced  to 
be  in  that  locality,  such  an  association  between  person  and  place, 
or  between  two  unlike  persons  and  the  place  where  they  were  at 
the  same  time,  and  consequently  between  the  respective  images, 
is  extrinsic,  because  here  we  have  to  deal  only  with  a coincidence 
which  does  not  touch  the  nature  or  the  form,  of  the  objects. 

Associations  are  also  divided  by  certain  psychologists  (Wundt, 
Kraepelin,  Aschaffenburg)  into  two  great  classes  : immediate  and 
mediate  associations.  The  latter  are  produced  through  the  medium 
of  a common  term  without  this  term,  itself  appearing  in  conscious- 
ness. Language  offers  a good  field  for  experiment.  Immediate 
associations  are  further  divided  into  two  groups,  according  as  the 
word  pronounced  is  understood,  or  has  evoked  an  association  in  its 
quality  of  a simple  sound.  When  the  word  is  understood,  we  have 
co-ordinated  and  subordinated  associations,  as,  for  example,  when 
the  word  statute  calls  up  the  word  law,  asylum  suggests  madness, 
nightingale  suggests  bird  ; or  the  relation  of  the  associated  words  is 
predicative,  as  in  ripe  fruit,  black  ink  ; or  is  casual,  as  in  merit, 
decoration,  alcohol,  inebriety.  These  are  internal  associations.  Ex- 
ternal or  extrinsic  associations  are  due  to  co-existence  in  space  and 
time,  or  to  identity  of  sound. 

Examples  of  association  through  co-existence  are  : mouth  and 
nose  ; pen  and  paper  ; ink-bottle  and  desk.  Synonyms  and  words 
translated  into  another  language  originate  external  associations, 
but  these  might  be  due  also  to  identitv.  Then  there  are  associations 
due  to  verbal  reminiscences,  like  the  words  that  always  com,e 
together  in  a proverb  or  a common  saying. 

When  the  word  is  not  understood  it  acts  only  as  a sound,  and  its 
effect  depends  very  m.uch  on  the  termination  of  the  word.  In  such 
a case  the  association  is  due  to  sound  and  rhyme,  with  or  without 
sense.  If  the  word  is  simply  repeated  there  is  only  a motor  associa- 
tion of  reaction. 

Bourdon  distinguishes  four  forms  of  verbal  associations  : 

1.  Phonetic  associations  without  significance,  and  due  to  resem- 
blance. 

2.  Grammatical  associations  of  nouns  and  nouns,  nouns  and 
adjectives,  nouns  and  verbs,  etc. 

3.  Associations  due  to  the  signification,  without  representation  of 
concrete  images. 

4.  Associations  with  representation. 

External  associations  are  more  frequent  than  internal  (x\schaffen- 


PHYSIO-PATHOLOGY  OF  IDEATION 


307 

burg)  ; they  are  also  more  rapid.  Associations  of  nouns  are  much 
more  frequent  than  those  of  verbs. 

We  have  said  that  associations  are  co-ordinative  and  subordina- 
tive  ; quality  is  associated  with  object,  object  with  quality,  and  so, 
in  another  field,  letter  is  associated  with  letter,  word  with  letter, 
the  name  of  a colour  with  a letter,  a word  with  another  word,  a 
number  with  a colour  (Calkins). 

Here  we  have  one  of  the  reasons  of  the  intellectual  differences 
between  men.  In  some  men  co-ordinate  associations  prevail,  others 
associate  more  frequently  and  easily  through  subordination  ; hence 
arises  in  part  the  variety  of  syntactical  forms  of  speech.  It  is  the 
difference  of  association  that  impresses  a particular  character  on  the 
intellect  ; for  instance,  the  intellect  of  the  reasoner  differs  from  that 
of  the  descriptive  writer,  owing  to  the  relative  homogeneity  of  the 
mind  of  the  reasoner  compared  with  that  of  the  descriptive  writer 
(Bourdon). 

Some  distinguish  associations  into  persistent  and  non-persistent, 
into  total  and  partial  (between  objects,  or  between  the  elements  of 
which  the  objects  are  composed).  There  are  associations  focalized, 
due  to  one  sole  element.  Then  there  are  simultaneous  and  succes- 
sive associations,  into  which  the  relations  of  space  and  time  enter  as 
constituent  elem,ents.  Simmltaneous  associations  present  themselves 
under  three  forms  (Wundt)  : 

1.  Fusion — that  is,  the  fusion  of  two  connotations  or  sensations 
of  the  object  perceived— such  as  the  colour  and  the  perfume  of  the 
rose,  the  colour,  or  the  shape,  and  the  taste  of  the  orange. 

2.  Assimilation,  which  is  a fusion  of  more  complex  components. 

3.  Complication,  in  which  there  are  evoked  images  referable  to 
different  senses,  as  when  the  sound  of  a bell  calls  up  the  visible  image 
of  it,  and  the  distant  associations  between  certain  movements  and 
certain  words,  such  as  those  that  express  a definite  mode  of  motion. 

A.  Anastay  relates  (Congr.  Inter,  de  Psychol.,  1900)  that  during 
a journey  he  was  unable  to  recall  the  name  of  a river.  At  night  he 
went  to  bed  annoyed  at  such  a lapse  of  memory,  and  set  himself  once 
again  to  recall  the  name,  but  without  result.  In  order  to  send 
himself  off  to  sleep,  he  started  to  dance  vigorously,  and  all  at 
once  the  name  recurred  to  him.  It  was  Ubaye,  or,  according  to 
the  local  pronunciation,  Ubaylle,  and  the  resemblance  of  the  name  to 
the  word  bailler  (to  dance)  evoked  by  his  dancing  established  the 
association. 

We  have  further  to  note  association  due  to  similarity  (Bain, 
Spencer,  Hofding,  Calkins). 

Association  is  rarely  mediate,  as  is  proved  by  the  experiments 
of  Scripture,  Howe  (Amcerican  Journal  of  Psych.,  1893-1895),  and 
W.  Smith.  Miinsterberg,  again,  denies  mediate  association.  In  the 
experiments  of  Howe,  who  constructed  a series  of  words  with  a 
meaning,  and  placed  after  each  word  a meaningless  syllable,  we  have 

20 — 2 


3o8 


PSYCHIATRY 


examples  of  mediate  association.  The  subject  listens  to  a first  series, 
then  a second  series,  and  then  the  first  series  is  repeated  to  him  ; 
if,  on  hearing  a word  of  the  first  series,  he  remembers  the  word  which 
follows,  separated  by  the  meaningless  syllable,  that  is  a mediate 
association.  Such  associations,  according  to  the  experiments  of 
Aschaffenburg,  hardly  reach  the  proportion  of  4 per  cent. 

The  time  and  the  number  of  associations  vary  very  much  in 
different  individuals.  This  variety  has  been  proved  by  many 
experiments,  among  which  those  of  Aschaffenburg  deserve  remem- 
brance Experimentelle  Studien  ilher  Associationen^ — Psychol. 
Arbeit,  I.  P.). 

If  a word  is  pronounced  to  the  subject  of  experiment,  and  he 
writes  down  all  the  words  that  it  suggests  to  his  mind,  to  the  number 
of  100,  or  if  he  associates  with  it  another  word  of  similar  or  different 
significance  in  the  shortest  time  possible,  the  time  being  measured 
for  each  experiment,  we  shall  have  in  a certain  way  a measure  of 
the  verbal  associations  in  a given  time. 

Among  the  associations  that  are  meantime  much  neglected 
by  psychologists  are  those  due  to  contrast.  Associations  due  to 
contrast  are  among  the  most  frequent  and  most  active  in  the  process 
of  thought,  and  they  furnish  the  most  plausible  explanations  of  an 
infinity  of  normal  and  morbid  phenomena  which  would  otherwise 
remain  quite  obscure.  In  some  intellectual  and  affective  categories, 
the  first  and  last  components  of  the  series  are  more  closely  associated 
than  any  of  the  intermediate  components. 

In  the  field  of  sensation,  white  is  more  closely  connected  with 
black  than  with  the  intermediate  shades  of  gray  ; the  image  of  the 
heaviest  body  is  closely  associated  with  that  of  the  lightest  body. 
The  representation  of  smoothness  is  associated  with  that  of  rough- 
ness, etc. 

In  the  domain  of  feelings,  pleasure  and  pain  come  together, 
although  they  are  the  extremes  of  a series  of  gradations  of  pleasure, 
gradations  of  pain,  and  of  different  sensations.  Friendship 
supposes  enmity,  love  supposes  hatred,  fear  supposes  courage,  and 
so  on.  As  we  mount  in  the  scale,  the  beautiful  supposes  the  ughq 
the  moral  the  immoral,  the  perfect  the  imperfect,  the  wholesome  the 
unwholesome,  the  illiterate  the  cultured. 

Many  such  contrasts  are  the  negative  side  of  an  afiirmation. 
When  I judge  men  good,  moral,  beautiful,  cultured,  disciplined,  I 
form  equally  and  simultaneously  comparative  judgments,  and  I 
represent  to  myself  bad,  immoral,  ugly,  uncultured,  undisciplined 
men,  whose  images  are  closely  associated  with  those  of  the  others, 
in  such  a way  that  whenever  I summon  up  any  of  one  series,  imme- 
diately the  correlative  of  the  other  series  corresponds  to  it. 

The  law  is  that  associations  due  to  maximum  difference  are 
stronger  than  those  due  to  resemblance  or  minimum  difference. 

Contrasts  establish  themselves,  from  the  first  appearance  of 


PHYSIO-PATHOLOGY  OF  IDEATION 


309 


mental  associations,  side  by  side  with  associations  due  to  resemolance 
and  to  contiguity.  When  an  infant  stretches  out  his  little  hand 
towards  a burning  light  and  feels  the  pain  of  the  burn,  he  notes  and 
remembers  the  contrast  between  the  pleasing  aspect  of  the  bright 
light  and  the  pain  that  results  from  contact  with  it.  If,  in  order  to 
wean  her  child,  a mother  puts  some  bitter  solution  on  the  nipple, 
there  arises  a strong  association  of  contrast  between  the  pleasure  of 
sucking  and  the  repellent  bitterness  of  the  nipple.  The  smile  in- 
spired in  an  infant  by  the  playful  attitude  of  the  father  becomes 
associated  with  the  painful  expression  induced  by  the  father  s 
severe  behaviour. 

The  whole  education  of  infants  rests  upon  the  law  of  psychic 
contrast.  Aspirations,  desires,  movements  that  are  opposed  and 
hindered,  associated  as  they  are  with  the  opposite  tendencies  of 
the  mind  and  the  relative  associated  ideas,  furnish  very  numerous 
examples  of  association  by  contrast.  Love  and  hate,  confidence  and 
diffidence,  hope  and  fear,  are  the  emotions  most  frequently  alter- 
nating in  consciousness,  being  ever  in  contact,  as  it  were,  on  its 
threshold  ; and  whenever  one  disappears  the  other  occupies  its  post. 
Dumas,  unlike  many  psychologists  who  either  make  no  mention  of 
psychic  contrast  or  deny  it  altogether,  like  Hartley,  J.  Mill,  and 
Stuart  Mill,  wrote  : ‘ Man  is  a very  strange  animal,  wholly  made  up 
of  contrasts.’  After  Bain,  no  one  has  elucidated  the  importance  of 
the  phenomena  of  contrast  in  the  succession  and  association  of  ideas, 
emotions,  and  acts,  more  fully  than  Paulham  V Association  par 

Contraste  ’ — Revue  Scientifique)  and  S.  de  Sanctis  (/  fenomeni  di 
contrasto  in  Psicologia,  Roma,  1895). 

Here  also  pathology  throws  a clear  light  on  a fact  that  is  of 
the  greatest  importance  to  psychology  in  the  interpretation  of  many 
physiological  and  pathological  phenomena. 

The  intense  love  that  the  neuropathic  mother  has  for  her  child 
awakens  in  her  consciousness,  in  contrast  with  the  joy  of  possessing, 
the  fear  that  some  illness  may  carry  off  the  infant  ; or  it  may  be  that 
when  she  leans  upon  the  balcony  she  fears  that  she  will  cast  down  the 
object  of  her  love.  A little  further  on  we  shall  see  how  many  other 
psychic  disturbances  are  to  be  interpreted  solely  through  associa- 
tions due  to  contrast,  and  how  much  more  frequent  than  is  generally 
believed  are  the  cases  of  delirium  due  to  contrast. 

As  far  back  as  1886,  in  a study  on  psychic  polarization  [Archivio 
di  Psichiatria,  Scienze  Penali  e Antr.  Crim.,  1886),  I set  forth  clearly 
the  principle  of  association  through  contrast.  ‘ This  fundamental 
logical  process,’  I then  wrote,  ‘ is  the  resultant  of  the  associative 
relations  of  the  sensations  and  of  the  ideas,  especially  the  relations 
of  antithesis,  with  which  are  associated  analogous  states  of  pleasure 
and  pain.  From,  the  very  force  of  the  function  of  reasoning  to  a con- 
clusion in  the  normal  process  of  mental  life,  it  results  that  every  idea 
bears  with  it  the  antithetic  idea  ; but  the  attention  directing  the 


310 


PSYCHIATRY 


latter  does  not  reach  the  visual  field  of  consciousness,  it  remains 
suppressed,  but  not  inactive,  in  the  unconscious.  . . 

I am  of  opinion  that  even  to-day,  after  many  years,  this  idea  may 
serve  as  an  explanation.  The  idea  in  contrast  surprises  the  con- 
sciousness when  the  attention  has  been  for  a long  time  directed  to 
the  other  idea.  De  Sanctis  lays  down  as  a condition  of  contrast  the 
intense,  prolonged,  and  inopportune  convergence  of  the  voluntary 
attention  upon  an  idea.  That  is  true  only  in  some  cases,  because 
pathological  contrast  depends  also  on  the  weakening  of  the  directive 
power  of  the  will  corresponding  to  the  increased  power  of  auto- 
matism, and  the  exalted  emotional  tone  of  the  mind— features  that 
have  been  present  in  every  case  that  I have  observed. 

I agree  unreservedly  with  De  Sanctis  as  to  the  other  factor  that 
he  notes  as  facilitating  pathological  contrast,  viz.  : ‘ The  permanent 
or  periodic  deficiency,  be  it  partial  or  general,  of  cohesion  among  the 
elements  constituting  the  aggregate  personality  and  the  consequent 
want  of  unity,  of  synthesis,  and  of  power  to  will  or  to  inhabit.  . . .’ 

The  contrasted  idea  is  often  the  primary  one,  and  is  eliminated 
by  its  antithesis,  which  expels  it  from,  the  purview  of  active  conscious- 
ness. 

Freud  and  others  have  noted  that  when  an  individual  proposes 
to  himself  to  do  something,  ideas,  more  or  less  actively  in  contrast 
with  this,  present  themselves  to  his  consciousness — the  Gegenwillc 
of  the  Germans.  The  mental  phenomena  experienced  by  Socrates, 
of  which  we  have  detailed  descriptions,  and  which  were  attributed 
to  his  ‘ daimon  ’ (Lelut),  are  nothing  more  than  phenomena  of 
ps}^chic  contrast  ; and  so  also  are  the  motives  and  counter-motives 
that  dispute  with  one  another,  in  the  field  of  consciousness,  the 
government  of  our  actions. 

It  is  well  known  that  there  are  a number  of  individuals,  especially 
hysterical  subjects  and  neuropathic  children,  who  always  act 
contrary  to  the  order  or  the  recommendation  given  them.  Some  of 
these,  when  they  wish  to  avoid  disturbing  bystanders  by  sneezing  or 
yawning,  actually  direct  their  wills  to  yawning  or  sneezing  (contrast 
by  inhibition). 

The  anxious  fear  of  committing  some  act  that  is  dangerous  or 
repugnant  to  the  conscience,  drives  into  the  field  of  consciousness 
all  the  images  connected  with  that  act  ; and  those  images,  especially 
in  degenerates,  are  endowed  with  an  excito-motor  power  and  an 
extraordinarily  impulsive  activity.  Therein  lies  the  explanation  of 
the  fact  that  those  who  are  greatly  afraid  of  death,  and  especially  of 
suicide,  end  by  committing  suicide  (coercion  due  to  contrast). 

Vows  of  chastity  and  religious  practices  often  excite  intensely 
erotic  ideas  and  desires.  The  hysterical  erotism  that  claimed  so 
many  victims  in  the  monasteries  of  the  Middle  Ages  was  the  contrast 
of  the  chastity  to  which  monastic  orders  and  sects  vowed  themselves 
(Bianchi,  II  ncvrosismo  di  questa  fine  di  secolo,  1899).  Such  a 


PHYSIO-PATHOLOGY  OF  IDEATION  311 

contrast  is  depicted  in  one  of  the  most  celebrated  paintings  of  Morelli 
— ‘ The  Temptation  of  St.  .Anthony-’  Santa  Teresa  was  tormented 
by  libertine  and  lascivious  ideas  whenever  she  thought  of  chastity 
(Lemesle). 

A little  farther  on  we  shall  see  how  many  psychopathic  pheno- 
mena, and  above  all,  how  many  cases  of  delirium,  depend  upon 
association  through  contrast.  Here,  again,  we  see  clearly  that  we 
cannot  complete  our  knowledge  of  the  facts  of  normal  psychology , 
or  of  the  laws  regulating  healthy  mental  life,  except  by  the  analysis 
of  pathological  phenomena. 

Associations  may  undergo  a species  of  interference — an  analogy 
applied,  inaptly,  in  the  strictly  physical  sense  of  the  term,  by 
A.  Bergstrdm  (‘  Experiments  upon  Physiological  Memory  by  Means 
of  Interference  of  Associations,’  Amer.  Jour,  of  Psychol.,  1892). 
Interference  of  associations,  says  this  author,  is  a fundamental  fact 
of  the  nervous  system,  and  consists  in  this,  that  once  an  association 
is  established  between  two  terms  A and  B,  if  a new  association 
be  sought  between  A and  C,  the  second  is  in  conflict  with  the  first. 

In  general,  when  we  wish  to  exchange  a.  habitual  mode  of  doing 
a thing  for  another  mode,  the  old  habit  resists,  and  when  we  are 
wearied  or  busied  with  some  other  matter  the  tendency  is  to  revert 
to  the  old  fashion.  The  law  of  interference  is  just  as  fundamental 
as  that  of  habit,  which  has  been  so  thoroughly  treated  by  James. 
The  reason  why  we  are  not  inclined  to  novelty  lies  in  the  fact  that 
we  are  unwilling  to  make  the  effort  required  for  new  associations. 
This  is  referable  to  another  law  of  life — the  law  of  least  resistance. 
Bergstrom’s  experiments  are  directly  intended  to  prove  the  fact 
that,  notwithstanding  every  effort,  a decided  interference  takes 
place  when  we  endeavour  to  associate  a new  reaction  with  an  old 
stimulus,  just  as  when  something  is  learned  in  a new  or  different 
fashion.  The  confusion,  writes  Bergstrom,  that  we  find  in  the 
mind  of  young  students  when  an  argument  is  presented  to  them 
under  a different  form  is  an  illustration  from  another  field.  Much 
of  what  has  been  attributed  to  the  failure  of  memory  with  age 
ought  to  be  placed  in  the  category  of  interferences.  In  my  opinion 
it  ought  to  be  attributed  also  to  the  mnemonic  capacity  of  the 
various  individuals. 

The  factors  of  association  are  many,  and  they  cannot  all  be 
examined  by  experimental  methods.  The  experiments,  however, 
of  Muller  and  Lehmann  (‘  Experimentelle  Beitrdge  zur  Unter- 
suchung  des  Geddchtinisses'—Zeitschr.  /.  Psych,  und  Physiol,  d. 
Sinn,  VI.)  brought  to  light  numerous  facts  regarding  association 
from  the  point  of  view  of  memory  ; for  example,  two  syllables  of 
one  series  separated  by  one  or  more  syllables  ; the  association 
between  that  which  follows  and  that  which  precedes  ; the  stronger 
association  between  the  odd  syllables  than  between  the  even,  for 


312 


PSYCHIATRY 


the  reason  that  the  former  are  pronounced  with  more  emphasis 
than  the  latter  ; the  association  with  the  position  occupied  by  the 
syllable,  with  the  rhythm  with  which  it  is  enunciated,  etc. 

Potency  of  association,  which  gives  us  evocative  imagination, 
is  not,  however,  regulated  by  any  of  the  known  laws  of  association, 
nor  does  it  always  require  a clear  memory  or  any  considerable 
wealth  of  sensible  representations  to  serve  all  its  combinations. 
In  it  there  come  into  play  the  elements  of  hazard  and  logical  inco- 
herence (Vaschide).  According  to  this  acute  observer  the  first 
di  earns  of  infants,  like  the  fibs  told  by  young  children,  are 
phenomena  of  creative  imagination  based  on  the  absence  of  precise 
perception  of  the  real  facts,  or  upon  error  of  the  senses. 

Who  can  say  under  how  many  different  aspects  things  may  be 
regarded,  and  how  different  are  the  imaginative  judgments  of  the 
most  similar  objects  ! If  little  drops  of  ink  are  allowed  to  fall  on 
pieces  of  cardboard,  and  if  we  press  other  pieces  of  cardboard 
upon  these,  the  ink  squeezed  out  will  make  spots  of  various  shapes 
on  the  said  pieces.  In  such  spots  one  child  will  see  a horse,  another 
child  an  animal  with  its  mouth  open,  while  another  will  find  there 
the  head  of  his  teacher  or  of  his  teacher’s  wife,  all  of  them  noting 
the  strangest  resemblances.  A housewife,  on  the  other  hand,  will 
see  m these  spots  domestic  articles,  while  the  artist  and  the  mytho- 
logist  will  see  picturesque  and  fantastic  objects.  This  is  not  a 
case  of  illusion  but  of  associations,  due  to  likeness  or  analogy  of 
all  these  objective  figures  with  others  that  are  preformed  and  very 
readdy  reproducible  in  memory  (Dearbon,  ‘ A Study  of  Imagina- 
tion,’ Amer.  Jour,  of  Psychol.,  1901). 

Protracted  mental  work,  according  to  the  researches  of  Asch- 
affenbuig,  exercises  a notable  influence  on  the  associative  power 
and  on  the  forms  of  association.  With  fatigue,  the  number  of 
mteinal  associations  diminishes  considerably  ; while  the  number  of 
external  associations,  such  as  those  formed  between  the  sounds  of 
words,  increases  with  the  duration  of  labour,  there  being  special 
increase  in  rhymes.  Associations  arising  through  co-existence  in 
space  and  time  likewise  diminish  in  number  with  fatigue. 

The  researches  of  Aschaffenburg  coincide  with  those  of  Binet 
on  the  influence  of  intellectual  fatigue  on  the  memory 
(A.  Binet  and  V.  Henry,  La  Fatigue  intellectuelle,  Paris,  1898). 
These  researches  should  prove  of  great  value  to  pedagogues  and  to 
the  compilers  of  schemes  of  study  for  schools. 

Association  between  ideas  has  a bearing  on  the  formation  of 
propositions,  which  include  a judgment  or  a conclusion  on  the 
relation  of  two  or  more  of  these  associations. 

These  associations  are  either  modified  reciprocally,  as  when  I 
say,  ‘This  asylum  was  a convent’;  or  they  are  co-ordinated,  as 
V len  I say.  Nuns  once  lived  here  where  now  are  madmen  ’;  or 


PHYSIO-PATHOLOGY  OF  IDEATION 


313 


they  fuse  together,  as  when  I sa}^  ‘ That  distant  black  spot  was  a 
squadron  of  cavalry.’ 

According  to  Brentano  and  Vailati  propositions  may  be 
divided  into  three  categories  : explicative  propositions,  obser- 
vational propositions,  and  normative  propositions.  These  three 
categories  of  propositions  correspond  to  three  fundamental  forms 
of  judgments,  which  comprehend,  according  to  these  authors,  all 
the  constructive  and  explicative  forms  of  thought.  The  first  cor- 
respond to  representations,  and  form  analytical  judgments  (Kant), 
or  judgments  determinative  of  relations  ; the  second  express  judg- 
ments of  assent,  or  of  doubt,  as  opposed  to  affirmations,  the  contents 
of  which  are  supposed  already  to  be  known  ; the  third  category  is 
composed  of  propositions,  of  appreciations,  and  of  judgments  of 
value. 

Every  proposition  contains  the  elements  of  conviction  in  so  far 
as  ever}^  conclusive  judgment  tends  to  affirm  or  to  deny,  and  so 
conviction  appears  as  a phenomenon  of  association  of  a higher 
order,  and  would  not  be  possible  but  for  general  ideas. 

Reasoning,  which  is  essentially  made  up  of  propositions,  is 
nothing  else  than  a more  extended  and  complex  association  of 
propositions,  the  associated  components  of  which  possess  cor- 
relations of  time,  space,  and  number,  from  which  arise  the  gram- 
matical inflections  of  words  and  the  syntactical  forms  that  are  the 
product  of  a more  advanced  mental  evolution. 

From  what  has  been  said,  it  is  clear  that  in  the  examination  of 
the  intelligence  we  must  keep  before  us  the  quantity  of  the  ideas, 
their  complexity,  whether  simple  or  fused,  their  re-evocation,  their 
associations  and  combinations,  the  constructive  property  of  the 
mind,  with  its  ideative  content  in  relation  with  the  percepts  or 
with  the  thought  of  the  social  medium  (judgments,  beliefs),  and  the 
form  of  language. 

The  anatomical  substratum  of  thought  comprises  the  whole 
cerebral  mantle.  On  this  point  I have  said  sufficient  in  Part  I.  and 
in  the  chapters  on  perception  and  memory.  If  we  bear  in  mind 
that  the  elementary  components  of  concrete  images  are  required  to 
maintain  these  latter  alive  and  e vocable,  just  as  the  presence  of 
these  is  necessary  to  evoke  all  the  associated  components  in  the 
respective  perceptive  zones,  from  which,  as  a whole,  we  draw  the 
complete  notion  of  objects  ; if  concrete  images  are  necessary  for 
the  formation  of  the  products  of  synthesis  or  of  fusion,  wherever  we 
have  synthesis,  it  may  be  concluded  that  the  whole  of  the  brain 
assists  more  or  less  in  the  formation,  representation,  and  expression 
of  thought.  The  sensory  areas  of  the  cerebral  mantle,  in  so  far  as 
they  furnish  the  images  of  the  external  world  ; the  area  devoted  to 
synthesis  or  the  fusion  of  the  sensory  products  into  psychic  pro- 
ducts of  higher  intellectual  value  ; all  the  zone  of  language,  in  so  far 


314 


PSYCHIATRY 


as  it  furnishes  the  sensory  and  kinaesthetic  images  of  speech,  in 
which  thought  is  moulded  and  formed — all  make  their  specihc  con- 
tributions. These  different  parts  of  the  mantle  are  connected  and 
brought  into  communication  with  one  another  by  means  of  associa- 
tive paths,  of  which  the  best  known  have  already  been  described 
in  the  first  part  of  this  work. 

There  we  have  ah  that  is  known  with  any  certainty  about  the 
anatomical  basis  of  intelligence  on  the  morphological  side.  This 
supposes  a normal  structure  of  the  nerve-elements,  cells  and  pro- 
longations, and  normal  relations  (not  yet  decided)  between  these. 
The  seductive  hypothesis  of  Rabl-Ruckard,  of  a network  of  fine 
nerve-fibres  (neurospongium)  formed  of  numerous  small  branches 
originating  in  the  protoplasmic  prolongations,  serving  as  the  seat 
of  and  as  the  pathway  for  the  interchange  of  the  elementary  and  the 
higher  psychic  processes,  and  the  other  hypothesis  formulated  by 
Mathias  Duval,  Lepine,  and  others,  as  to  the  amoeboidism  of  the 
cell  prolongations,  enjoyed  only  momentary  favour  It  was  cer- 
tainly very  convenient  to  explain  the  phenomena  of  thought,  sleep, 
hysterical  paralysis,  and  hypnotism,  by  the  doctrine  of  the  expan- 
sion and  contraction  of  the  nerve  ramifications  ; but,  as  Kolliker 
observed  with  regard  to  the  first,  and  as  is  proved  by  the  recent 
researches  of  Michelina  Stefanovska,  there  is  not  a single  fact  in 
proof  of  the  existence  of  amoeboid  movements  either  of  the  dendrites 
or  of  the  terminal  ramifications  of  the  neurons.  The  axis  cylinders 
do  not  undergo  contraction,  the  more  so  as  they  are  comparatively 
solid  and  organized  (fibrillar).  On  the  other  hand,  it  has  been 
impossible  to  prove  any  movement  of  the  nerve-endings  in  the 
transparent  parts  of  animals  observed  while  alive,  as  in  the  case  of 
the  larv«  of  the  batrachians. 

Cajal  himself,  who  supposed  a variable  histological  factor  to 
which  the  infinite  varieties  of  mental  work  might  be  referred,  has 
not  been  able  to  confirm  any  part  of  his  theory  by  objective  examina- 
tion, both  axis  cylinder  and  protoplasmic  ramifications  presenting 
always  the  same  extension,  the  same  form,  and  the  same  appearance. 
Stefanovska  says  : ‘ I have  never  been  able  to  observe  retraction 
or  contraction  of  the  dendrites  properly  so-called.  I have  observed 
only  the  retraction  of  the  pyriform  appendices  under  the  influence 
of  violent  blows,  under  electrification  of  the  brain,  and  in  profound 
anaesthesia,  which  is  only  a particular  form  of  poisoning.  In  other 
words,  the  disappearance  of  the  pyriform  appendices  is  always 
provoked  by  abnormal  causes  ’ (M.  Stefanovska,  ‘ Etude  histolo- 
giquc  du  Cerveau  dans  le  Sommeil  provoque  par  la  Fatigue^  Jour, 
dc  Neurologic,  igoo). 

Amoeboidism  is  also  denied  by  Ziegler  and  by  J.  Soury,  who 
stated  in  the  Revue  ghierale  des  Sciences,  i8g8,  that  the  histological 
theory  of  sleep  had  not  onl}^  added  to  the  obscurity  surrounding  the 
true  nature  of  the  cause  of  this  phenomenon,  but  had  created  in 


PHYSIO-PATHOLOGY  OF  IDEATION 


315 


many  sincere  minds  the  illusion  of  knowledge,  despite  the  warning 
of  kolliker.  3Ieanwhile  the  researches  of  Apaty  have  revived 
the  doctrine  of  the  relations  of  continuity  between  the  nerve  pro- 
longations, and  the  rapidl}^  constructed  theory  of  the  neuions  and 
am.cnboidism  is  falling  to  the  ground.  We  shall  wait  patiently 
until  new  and  well-ascertained  facts  give  us  the  means  to  set  our 
minds  at  rest,  troubled  as  they  are  by  the  darkness  still  obscuring 
the  question  of  the  anatomical  basis  of  the  phenomena  of  thought. 

The  anomalies  of  thought  are  quantitative  and  qualitative. 
Quantitative  anomalies  include  also  those  of  the  duration  of  the 
passage  of  thought,  in  so  far  as  this  passage  obeys  the  law  of  time, 
like  all  psychic  facts.  In  this  regard  there  are  disorders  referable 
to  the  unduly  long  time  required  for  formation  and  extrinsication, 
and  others  attributable  to  the  excessive  rapidity  of  development. 

Considered  in  itself,  excessive  rapidity  is  not  a disorder  of 
thought  or  of  ideation.  It  is  certainly  a disorder  with  regard  to 
the  usual  time  required  for  the  associative  processes  in  the  indi- 
vidual, because,  given  certain  morbid  conditions,  we  have  often, 
along  with  rapidity  of  thought,  superficiality  and  other  anomalies 
of  the  associative  mechanism,  giving  rise  to  changes  in  the  new 
ideative  series  and  the  logical  form  of  thought  itself. 

In  fact,  except  in  the  very  first  grades  of  certain  forms  of  maniacal 
exaltations,  in  which  some  exalted  persons  show  themselves  pos- 
sessed of  a strong  power  of  observation  and  of  memory,  rapidity 
is  not  generall}^  a morbid  condition  in  itself  unless  when  it  exceeds 
certain  limits  in  relation  to  each  single  individual,  and  is  associated 
with  other  anomalies  of  the  formal  process  of  thought,  such  as 
deficient,  superficial,  or  extraordinary  association  of  the  diverse 
elements  of  which  thought  is  constituted. 

In  mania,  in  the  pre-paralytic  stage  of  some  forms  of  progressive 
paralysis,  in  some  forms  of  acute  paranoia  and  acute  hallucinatory 
delirium,  and  in  some  cases  of  hysteria,  we  find  the  best  examples 
of  morbid  rapidity  of  thought. 

Wherever  there  is  diminution  of  intellectual  working  and  defect 
of  attention,  ideogenesis  may  be  accelerated  through  the  association 
of  indirect  ideas  (Aschaffenburg).  Hallucinations  also  have  power 
to  increase  the  rapidity  of  the  formation  of  ideas  (Ziehen). 

We  need  not  repeat  here  what  has  already  been  said  when  we 
were  speaking  of  hypermnesia  ; we  need  only  add  that  morbid 
rapidity  of  representation  is  accompanied  by  modifications  of  the 
phenomena  of  association.  These  become  more  frequent  with 
regard  to  the  forms  of  things  and  the  sounds  of  words  (external 
associations)  than  for  the  substance  of  things  and  the  meaning  of 
words  (internal  associations). 

A lady  who  had  just  emerged  from  a state  of  intense  maniacal 
excitement  said  : ‘Now  I am  much  better,  but  in  the  past  few 
days — in  which  I had  loosened  an  exceptional  ligament  of  the 


3i6 


PSYCHIATRY 


tongue — I have  had  an  extraordinary  number  of  ideas.  I did  not 
succeed  in  expressing  them  all  ; and  ideas  that  I had  never  had 
before,  or  that  I had  lost  for  a long  time,  came  to  me  all  at  once.’ 

In  such  cases  there  is  an  extraordinary  awakening  of  recollec- 
tions and  of  various  ideas  that  have  no  strong  associative  connection 
with  each  other.  True  associations  have  not  time  to  form,  and  ' 
instead,  there  is  a predominance  of  motor  association,  whence  the 
rapid  manifestation  of  thought  in  words  and  in  acts.  Here  we  are 
dealing  with  rapid  representations  of  the  movements  of  words 
(association  through  rhyme,  phonemata).  Often  in  such  cases,  all 
the  ideas  have  not  even  time  to  secure  expression  for  themselves, 
either  in  language  or  in  gesture.  Sometimes  the  patients  are  in  a 
condition  to  make  what  I might  call  a selection  among  the  ideas 
that  crowd  into  the  field  of  consciousness,  and  to  order  them  so 
that  their  speech  is  logical,  although  empty  of  meaning  and  mingled 
with  proverbs,  neologisms,  and  witticisms.  In  the  more  advanced 
stages,  there  are  seldom  wanting  other  pathological  facts  that  deserve 
greater  consideration : superficiality  of  judgment  of  the  actual 
perceptions  ; paradoxical  connection  of  ideas,  giving  rise  to  strange 
thoughts  that  are  often  brilliant  in  appearance  but  comparatively 
empty  ; errors  of  judgment  as  to  the  relations  of  the  subject  to  his 
environment — these  are  the  most  common  phenomena.  At  other 
times  the  cerebral  excitability  is  increased  to  such  a degree  that  the  ' 
slightest  external  or  internal  stimulus,  or  the  most  trifling  recollec- 
tions, are  sufficient  to  awaken  a number  of  others  that  chase  each 
other  through  consciousness,  and  form  a nexus  with  the  preceding, 
though  without  any  regular  relation  to  them.  Thought  becomes 
disgregated,  assuming  the  most  distant  associations,  often  due 
solely  to  the  sound  of  the  words  ; speech  becomes  disconnected 
and  almost  totally  incoherent,  owing  to  the  torrent  of  ideas  that 
rushes  over  and  overwhelms  the  psycho  - motor  paths  (tumultus 
sermonis). 

On  the  other  hand,  thought  may  be  morbidly  slow.  There  are 
individuals  who  regularly  formulate  and  express  their  thoughts 
with  much  slowness  ; still  the  slowness  remains  within  physiological 
limits. 

We  have  sometimes  a more  or  less  notable  activity  of  attention, 
and  a strong  logical  connection  between  ideas,  coinciding  with  such 
slowness.  But  there  are  cases  in  which  the  time  required  is  ex- 
cessively long,  and  the  thought  is  developed  with  great  slowness, 
yet  it  shows  no  true  formal  anomalies  in  its  constitution.  The 
individuals  presenting  this  phenomenon  are  in  various  pathological 
conditions. 

It  ma}'  be  that  the  mind  is  in  pain.  Pain  is  a condition  of 
arrest,  which  implies  a centripetal  direction  of  the  nerve-waves 
towards  the  consciousness,  and  therefore  greater  resistance  in  their 
cxtrinsication.  The  velocit}^  is  in  inverse  ratio  to  the  resistance. 


PHYSIO-PATHOLOGY  OF  IDEATION 


317 


and  so  it  comes  about  that  where  there  is  most  pain,  and  therefore 
resistance,  there  also  is  the  greatest  slowness  in  the  course  of  ideas, 
extending  to  complete  arrest.  Physical  and  moral  pain  are  the 
same  thing  as  far  as  the  laws  of  thought  are  concerned.  The  state 
of  intense  emotion  of  the  person  suffering  morally  induces  a static 
condition  of  consciousness,  with  cumulative  action,  and  a tendency 
to  fix  in  consciousness  some  classes  of  ideas  to  the  exclusion  of 
many  others.  The  same  thing  occurs  when  attention  is  concen- 
trated on  a theme,  especially  if  that  should  possess  a strong  affective 
power  of  a painful  or  an  egoistic  nature.  In  all  states  of  strong 
emotion  in  which  there  is  a concentration  of  tension  in  conscious- 
ness, the  thought  that  is  not  connected  with  the  object  of  emotion 
will  not  have  the  initial  impulse  to  send  it  on  its  course  with  the 
usual  velocity,  or  there  will  be  opened  to  it  very  few  paths  (e.g.,  flight, 
or  defensive  movements  made  in  fear,  etc.). 

In  other  cases  we  have  diminished  functional  power  of  the  nerve- 
elements,  which  are  defective  in  the  energy--habitual  dynamo- 
genetic  force— required  to  overcome  the  resistance  offered  by  the 
multiple  and  complicated  paths  that  the  nerve-wave  has  to  traverse, 
and  to  make  way  against  the  contrasts  sometimes  produced  by  arrest 
or  interference  of  ideas,  rendering  necessary  for  these  a greater 
length  of  time  to  accumulate  the  tension  required  (recall  of  stimuli 
in  the  memory).  Sometimes  the  transmission  of  nerve-waves  over 
the  associative  paths  is  hindered,  with  the  result  that  we  have  a 
complex  thought  which  is  not  a simple  manifestation,  but  the 
resultant  of  a series  of  images  associated  over  a rich  network  of 
nerve-filaments,  the  integrity  of  which  is  quite  as  indispensable  to 
the  process  of  thought  as  is  that  of  the  cell-elements.  It  is  thus 
that  we  explain  the  slowness  of  thought  in  individuals  with  cerebral 
tumour,  which  compresses  the  brain  substance  or  in  some  other 
way  subtilizes  the  network  and  obliges  the  currents  of  thought  to 
take  longer  courses,  or  shuts  the  paths  against  them  altogether,  so 
that  the  various  components  of  a thought  do  not  meet,  or  do  so 
only  irregularly  and  after  a long  time.  Hence  we  have  the  psycho- 
physical law  that  the  time  is  in  inverse  ratio  to  the  dynamogenetic, 
or  ideogenetic,  force  of  the  nerve-components,  ccBteris  paribus,  and 
in  direct  ratio  to  the  resistances  and  the  distances. 

Such  slowness  of  thought  gives  rise  to  a form  of  speech  called 
hradyphrasia — slowness  in  the  formation  of  phrases. 

Morbid  slowness  in  the  course  of  ideas  is  characteristic  of  pro- 
gressive paralysis,  of  lypemania — passing  on  to  the  complete  arrest 
met  with  in  the  stuporose  form  (melancholia  attonitans) — and  also 
of  hallucinatory  stupor.  We  meet  with  it  also,  in  a different  degree 
and  associated  with  a different  mechanism,  in  certain  cases  of 
paranoia,  in  organic  and  in  epileptic  stupor,  in  certain  forms  of 
neurasthenia,  and  in  epileptic  and  apathetic  dementia,  as  well  as 
in  encephalomalacia.  We  also  observe  it  occasionally  in  states 


PSYCHIATRY 


318 

of  fatigue  and  exhaustion,  after  strong  excitement,  and  as  a result 
of  intoxication  by  opium,  alcohol,  etc. 

Occasionally  some  ideas  preponderate  excessively  in  conscious- 
ness, where  they  take  up  a permanent  abode.  The  consciousness  has 
lost,  wholly  or  in  part,  its  power  of  selecting  and  eliminating  ideas. 

In  normal  conditions,  all  strong  stimuli  have  greater  permanence 
as  images  in  consciousness,  whether  the  emotion  accompanying 
them  be  pain  or  pleasure,  and  the  correlative  groups  of  ideas  do  not 
allow  them.selves  to  be  supplanted  by  others,  more  or  less  in  con- 
trast, until  after  some  time.  In  some  pathological  conditions, 
often  congenital,  such  as  degeneration  or  grave  psychopathic 
heredity,  the  percepts,  like  the  concepts,  remain  for  a long  time  in 
consciousness,  and  determine  a painful  state  of  mind,  as  well  as  ' 
a vain  struggle  against  themselves.  Degenerates,  and  sometimes 
neurasthenic  persons  in  this  condition,  being  always  emotional, 
lose  themselves  in  vain  and  futile  representations  and  acts,  and 
in  useless  and  repeated  attempts  to  liberate  themselves  from  the 
monotonous  content  of  consciousness.  Here  we  always  have  weak- 
ness, associated  with  illogical  emotions  ; but  these  ideo-emotional 
obsessions  are  not  systematized,  they  are  not  assimilated  with  the 
personality,  nor  do  they  assume  associative  relations.  Certainly 
they  impede  the  normal  course  of  ideas,  because  they  constitute  a 
species  of  internal  resistance  in  consciousness  (impeded  exchange 
and  diminished  eliminating  power  of  consciousness). 

We  must  also  note  the  ideative  void  that  is  painfully  noticeable  i 
in  some  forms  of  neurasthenia,  as  well  as  the  incapacity  to  direct  , 
the  thought.  In  these  last  cases,  there  is  a really  troublesome  ‘ 
heaping  up  of  thoughts  that  endeavour  to  break  the  associative 
chain  of  the  main  thought  which  it  is  desired  to  follow  out  or  to 
express.  A young  man  thus  suffering  wrote  to  me  ; ‘ Truly  I am  in  : 
torment.  Certain  vain  reflections  and  a number  of  inquisitive  and  ; 
captious  ideas  worry  my  existence  ceaselessly,  and  will  not  allow  | 
me  that  liberty  and  seriousness  of  thought  that  others  enjoy.’  ; 

Besides  the  time,  we  must  note  the  vivacity  of  thought — the  ' 
degree  of  illumdnation  that  it  receives  in  the  visual  point  of  con- 
sciousness. 

Even  from  a physiological  standpoint  we  find  herein  a great 
variety,  according  to  the  individual.  There  are  some  who  certainly 
conceive,  but  their  thoughts  are  colourless  and  inactive  ; they 
hardly  make  their  presence  known  on  the  threshold  of  consciousness, 
or  they  may  reach  the  visual  point  only  to  disappear  immediately 
without  leaving  any  traces  of  their  eflicac}^  just  as  if  all  the  ideo- 
motor paths  had  been  closed  against  them.  Others  there  are 
whose  conception  is  not  more  active,  but  with  them  the  same  . 
thoughts,  perhaps  in  the  same  form,  are  better  defined,  have  more 
colour,  are  more  active,  and  have  more  inherent  force.  The  laws 


PHYSIO-PATHOLOGY  OF  IDEATION 


319 


of  reaction  make  it  easy  for  us  to  understand  that  the  more  prompt 
and  energetic  the  reaction — words,  action,  inhibition — the  more 
intense  must  be  the  stimulus,  which  is  here  represented  by  the 
thought.  What  an  influence  this  law  might  exert  upon  the  con- 
duct and  the  mode  of  living  of  the  individual  as  well  as  of  society 
as  a whole  ! 

Sometimes  we  hear  the  remark,  ‘ I have  thought  that  myself.’ 
Yet  the  speaker  has  not  been  able  to  give  form  to  his  thought, 
because  it  failed  to  reach  the  degree  of  intensity  requisite  to  deter- 
mine action,  or  even  its  own  expression  in  words.  Another  man 
has  the  same  conception,  and  he  announces  it,  or  works  toward  the 
end  signified  by  the  nature  of  that  mental  representation.  Some- 
times it  is  simply  a case  of  the  more  vivid  colouring  that  the  thought 
assumes  in  consciousness,  and  therefore  the  mode  of  feeling  of  the 
subject  always  comes  into  play.  The  emiotional  co-efflcient,  which, 
as  we  shall  see  in  the  following  chapter,  is  always,  or  almost  always, 
associated  with  the  thought,  is  what  gives  more  or  less  interest 
to  representations,  colouring  them,  and  greatly  increasing  their 
excito-motor  potential.  The  colouring  depends  upon  feeling,  and 
upon  the  range  of  associations.  The  thought  may  be  involved  and 
confused,  or  determinate  and  definite . The  stronger  the  discriminat- 
ing and  eliminating  power  of  the  consciousness,  taking  away  from 
the  thought  all  those  components  that  are  least  serviceable  for  its 
actual  constitution,  the  more  lucid  is  the  thought.  There  is  still 
another  component,  however,  which  we  must  take  into  account — ■ 
viz.,  the  number  of  associations  lying  latent.  Not  only  do  the 
images  borne  into  the  field  of  consciousness,  through  the  selective 
power  of  the  latter,  contribute  to  the  luminosity  of  the  thought, 
but  also  the  remotest  bonds  of  association  of  that  thought  with 
others  which,  though  they  be  not  themselves  sumimoned  again  into 
the  field  of  consciousness,  yet  nourish  its  deepest  roots.  Many 
coefficients,  therefore,  concur  to  increase  the  energy  of  thought, 
but  above  all,  the  number  and  the  conductivity  of  the  associative 
threads,  which  render  thought  more  powerful  and  active  in  pro- 
portion as  they  are  numerous  and  facile,  in  accordance  with  the. 
greater  activity  of  the  cell-elements. 

The  colouring  and  the  luminosity  of  thought  are  of  great  signifi- 
cance, owing  to  their  influence  upon  the  reaction,  which,  in  its 
promptitude,  decision,  and  harmony,  gives  an  index  of  the  strength 
of  cerebral  organization.  They  excite  and  revive  interest,  which 
increases,  on  the  one  hand,  the  perceptive  potential  and  the  power 
of  selection  of  impressions  from  the  external  world,  and  on  the 
other  hand,  the  evocative  power  over  the  mental  patrimony — a 
power  that  sometimes  extends  its  operation  even  to  the  catacombs 
of  oblivion. 

That  thought  and  actual  perceptions  reciprocally  reinforce  one 
another  is  proved  by  many  facts.  If,  for  example,  we  forget  the 


320 


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name  of  a person  whose  image  is  clearly  represented  in  our  minds, 
we  may  be  certain  that  the  name  lies  buried  in  the  hiding-places  of 
memory,  notwithstanding  the  futility  of  the  efforts  we  may  make 
to  recall  it.  If  the  person  should  appear  before  our  eyes  his  name 
at  once  comes  to  the  lips.  It  is  clear  in  such  a case  that,  however 
well  defined  may  be  the  image  of  the  person  in  the  visual  field  of 
consciousness,  it  is  incapable  of  bringing  forth  the  verbal  representa- 
tion of  the  name  ; but  when  reinforced  by  the  actual  impression,  the 
verbal  image  comes  up,  the  vibrations  of  the  actual  impression 
being  added  to  the  weak  vibrations  of  the  mnemonic  image  (sum- 
mation of  stimuli). 

Facts  like  these  are  of  the  greatest  value  in  normal  and  patho- 
logical psychology,  for  the  reason  that  in  many  mental  maladies 
thought  has  not  actually  disappeared ; it  is  only  weakened ; it  has 
lost  its  colour,  and  therefore  cannot  take  up  its  governing  position  ; 
it  has  no  evocative  force  or  excito-motor  power.  Again,  a thought 
may  vanish,  driven  away  by  other  thoughts,  or  it  may  be  slow  of 
motion,  poor,  incomplete,  colourless,  and  inactive. 

This  condition  of  matters  is  an  ethnic  phenomenon  in  some 
countries,  and  is  always  met  with  when  the  organization  of  the 
nervous  system  is  congenitally  poor.  It  is  found  also  in  all  the 
weaklings  who  crowd  the  wide  borderland  separating  the  imbecile 
from  the  normal  man,  and  containing  a conspicuous  number  of 
frivolous  and  indifferent  persons.  The  condition  may  also  be 
acquired,  as  in  neurasthenia  and  in  states  of  mental  decadence, 
whatever  be  their  origin  and  their  nature. 

Lucidity  and  vigour  of  thought  have  also  a bearing  upon  the 
value  of  psychic  formations.  Here  we  must  consider  the  degree 
of  fusion  of  the  images.  When  the  mental  evolution  is  incomplete, 
the  fusion  is  arrested  at  the  formation  of  concrete  images  of  the 
objects  (imbeciles  and  idiots),  whilst  in  men  of  normal  evolution 
the  fusion  reaches  a high  development  in  the  formation  of  abstract 
thought,  attaining  its  highest  potential,  which  is  found  in  some 
forms  of  genius  characterized  by  exceptional  power  of  synthesis. 

All  the  disturbances  of  which  we  have  hitherto  spoken  do  not 
substantially  disturb  the  personality.  With  all  these  anomalies 
the  personality  still  retains  its  original  composition,  apart  from 
the  quantity  and  vigour  of  the  products  of  mental  effort  and  the 
new  emotional  states,  of  which  we  shall  speak  in  the  following 
chapter.  But  thought  may  be  altered  substantially  in  its  struc- 
ture, and  this  induces  a profound  change  in  the  personality,  which 
is  either  transformed  or  is  broken  up,  and  gives  birth  to  delirium  or 
confusion. 

Delirium*  is  a qualitative  disturbance  of  ideation.  As  I have 

* The  word  delirium  has  been  derived  from  the  Latin  de  lira,  to  go  out 
of  the  track  ; or  from  the  Greek  Xijpos,  stupid  talk.  I think  that  the 
Latin  derivation  de  lira,  to  leave  the  right  course,  is  preferable. 


PHYSIO-PATHOLOGY  OF  IDEATION 


321 


already  said,  ideation,  on  the  one  hand,  is  especially  founded  on 
the  mnemonic  reproductions  and  the  normal  laws  of  association  ; 
on  the  other  hand,  it  depends  upon  the  actual  perceptions  which 
put  themselves  into  relations  with  the  past  perceptions  that  have 
already  become  constituents  of  the  personality,  associating  and 
fusing  themselves  with  these.  The  personality  thus  constituted 
exercises  continuous  control  over  this  process,  in  the  sense  that  the 
personality  is  not  transformed,  but  is  constantly  being  increased 
by  new  acquisitions  resulting  from  the  percepts  continuously 
furnished  by  the  external  world.  It  advances  in  knowledge,  as  it 
were,  by  stages. 

The  formative  process  of  thought  is  altered  by  extraneous 
associative  relations  between  preformed  images,  drawn  sometimes 
from  the  unconscious,  or  between  already  acquired  ideas  and  the 
newcomers,  thus  giving  rise  to  a conclusion  which  does  not  cor- 
respond to  reality.  The  product  of  this  abnormal  process  goes 
under  the  name  of  delirium.  The  process  of  comparison  is  altered, 
and  comparison  is  so  fundamental  a psychic  factor,  that  without 
it  we  can  have  no  idea  of  quality,  intensity,  or  extension  ; or 
there  is  alteration  of  the  fundamental  processes  of  perception,  and 
therefore  we  come  to  judge  of  the  external  world  in  a manner  not 
corresponding  with  reality.  If  we  see  figures  or  hear  sounds  01 
words  that  nobody  is  producing  or  pronouncing,  or  if  we  hear 
differently  from  the  generality  of  persons  those  sounds  and  words 
that  are  produced  by  others,  or  if  we  see  figures  differently  from 
other  people,  or  have  ourselves  a different  idea  of  the  parts  of  our 
own  body  (tactile,  tactile-muscular,  organic  hallucinations,  etc.), 
we  end  by  formulating  judgments  upon  the  subjective  perceptions  ; 
and  these  do  not  correspond  to  the  objective  reality,  because  they 
are  merely  the  subjective  product  of  an  anomalous  function  of  the 
sensory  centres. 

Some  writers,  like  Sciamanna,  make  delirium  include  also  aberra- 
tions of  the  senses  (illusions  and  hallucinations),  and  the  delirium 
of  action  (forced  movements,  impulsive  actions). 

Delirium  stands  in  contrast  with  reality,  although  sometimes 
it  has  an  air  of  probability.  Sometimes,  in  fact,  and  especially  in 
delirium  of  persecution  and  of  grandeur,  within  certain  limits,  there 
may  be  correspondence  with  the  abstract  reality,  but  that  reality 
has  nothing  to  do  with  the  individual  who  attributes  it  to  himself. 

In  its  evolution,  delirium  almost  always  passes  the  bounds  of 
probability,  and  its  judgments  or  affirmations  become  utterly 
strange  and  paradoxical.  Sometimes  these  are  judgments  or  beliefs 
belonging  to  other  ages  or  to  the  lower  social  strata — beliefs  that 
have  long  passed  into  the  unconscious  or  into  oblivion.  Fairy 
tales,  tales  of  witches  and  their  ill-doings,  the  magic  stories  heard 
in  infancy,  religious  or  mystic  prejudices,  from  almost  all  of  which 
we  have  freed  ourselves  through  culture  and  a clearer  comprehension 

21 


322 


PSYCHIATRY 


of  natural  phenomena,  may  reappear  as  active  elements  of  our 
judgment  in  abnormal  conditions. 

In  adult  age  the  first  misfortune  met  with  is  interpreted  in  the 
fashion  of  the  lower  social  strata,  where  such  beliefs  are  common, 
being  attributed  to  witchcraft,  to  evil  spirits,  or  to  demons,  in  con- 
tradiction to  all  the  convictions  of  the  normal  personality.  That 
interpretative  conclusion  is  a delirium. 

In  these  cases  the  phantasy  creates  nothing  new  ; it  reproduces 
nothing  (by  atavistic  reversion)  that  belonged  only  to  past  genera- 
tions, nothing  that  did  not  belong  to  the  same  personality  at  some 
period  of  its  evolution — generally  childhood  or  youth. 

In  the  process  formative  of  the  personality  a number  of  percepts, 
beliefs,  and  prejudices  become  eliminated  by  selective  power.  The 
more  advanced  the  evolution  of  the  individual,  the  greater  is  the 
number  of  these  rejected  prejudices  thrown  up  from  the  dusty 
archives  of  the  unconscious.  If  the  personality  suffer  disease,  the 
records  become  disordered  by  that  very  fact,  and  the  ancient 
documents  then  furnish  Ariadne’s  thread  for  the  interpretation  of 
new  facts,  the  origin  of  which  escapes  criticism  in  the  changed 
conditions  of  existence.  The  mind  produces  nothing  that  does  not 
belong  to  itself  and  to  its  own  individual  history.  The  idea  of 
atavistic  reversion  in  the  genesis  of  delirium  fails  to  stand  the  most 
elementary  criticism.  At  other  times  there  are  paradoxical  con- 
ceptions of  the  nature  of  dreams,  manifested  or  not,  but  at  once 
corrected  by  more  just  perception  of  reality. 

When  all  the  mental  powers  are  enfeebled,  the  consciousness  is 
no  longer  in  a condition  to  eliminate  and  reject  such  mental  pro- 
ducts as  are  in  contrast  with  its  own  organization  or  with  prob- 
ability, and  these  products  acquire  a peculiar  power  of  invasion  and 
of  suggestion.  The  consciousness  is  subjected  to  their  transforming 
influence,  and  regulates  itself  by  these  new  mental  products  (deliria). 

In  my  youth  I had  a friend  who  made  himself  remarkable  above  ^ 
all  others  on  account  of  his  extravagant  ideas.  One  day,  for  i 
example,  on  a height  overlooking  the  Valle  Frentana,  he  exclaimed  : j 

‘ How  happy  I should  be  if  I had  as  much  gold  as  this  valley  holds  !’  j 
That  childish  desire  bears  a resemblance  to  very  many  states  of 
paralytic  delirium. 

I hold  that  deliria  are  always  preformed  mental  products  that 
have  been  eliminated  from  consciousness  at  an  early  date.  The 
consciousness  manages  for  a long  time  to  close  its  field  against 
their  ingressions,  but  it  happens  that  the  conditions  of  existence 
of  the  personality  gradually  change,  and  consciousness  offers  less 
resistance  to  the  invading  power  of  these  products. 

A proof  of  this  we  ha.ye  in  e\'ery  case  where  we  closely  examine 
the  history  of  the  delirious  subject.  A beguine  who  gives  herself 
up  to  religious  exercises  is  led  to  that  manner  of  life  by  two  concepts  | 
that  struggle  one  against  the  other  (psychic  contrast).  She  wishes 


PHYSIO-PATHOLOGY  OF  IDEATION 


323 


to  gain  the  grace  and  protection  of  God  and  to  escape  the  danger 
of  perdition.  The  objective  of  consciousness  is  the  grace  of  God  ; 
the  fear  of  the  devil  and  hell  remains  with  the  respective  images 
as  a threat  upon  the  threshold  of  consciousness.  Now,  it  follows 
that  if  the  consciousness  loses  in  any  degree  its  regulative  and 
selective  power,  in  the  case  of  a mental  organization  of  this  char- 
acter, the  grace  of  God  disappears  as  the  objective,  and  the  ideative 
constellation  of  hell,  demons,  and  damnation,  with  the  relative 
emotions,  is  substituted  for  it.  Thus  delirium  is  constituted  only 
because  an  old  psychic  formation  affirms  itself  in  the  consciousness, 
and  to  this  the  beguine  opposes  ideas  of  defence  and  aspiration, 
which  determine  the  character  of  her  personality  and  conduct 
(delirium  of  contrast). 

From  religious  preoccupation,  or  because  of  unhappy  circum- 
stances in  her  life,  a woman  makes  a vow  of  chastity,  or  perhaps 
lives  unwed  without  making  a vow.  The  ideo-emotive  group  of 
chastity  is  closely  associated,  although  in  contrast,  with  the  ideo- 
emotive  group  of  love,  which  latter  is  resisted  and  kept  upon  the 
threshold  of  consciousness  by  the  tension  of  contrast.  A number 
of  images,  ranging  from  the  mystic  to  the  erotic,  are  continually 
tending  to  invade  the  consciousness,  and  are  repulsed  ; but  if  the 
selective  and  regulative  power  of  consciousness  decays,  as  often 
happens  at  the  climacteric  age,  all  these  preformed  ideo-emotive 
groups  make  their  assault,  storm  the  citadel,  and  direct  the  active 
attention  of  consciousness  upon  the  external  world,  and  the  revived 
desires,  rendered  more  intense  by  long  waiting  until  youth  has 
passed,  give  an  illusory  perception  corresponding  to  the  images 
that  occupy  the  consciousness.  Thus  erotic  delirium  is  organized, 
the  dreams  of  youth  being  constantly  revived  by  the  unsatisfied 
instinct. 

Here  preformation  by  contrast  is  evident,  and  it  is  proved  by 
the  fact  that  I have  always  met  with  erotic  delirium  in  old  maids 
and  in  married  women  widowed  while  young  ; or  in  weak  males 
who  lacked  the  courage  to  make  love,  as  well  as  those  who  were 
impotent.  These  subjects,  male  and  female  alike,  are  always  pre- 
disposed by  heredity  and  degeneration,  and  have  poor  intellectual 
and  moral  resources. 

Delirium  due  to  contrast  is  much  more  frequent  than  is  believed 
by  the  greatest  authorities  on  psychiatry,  many  of  whom  do  not 
even  mention  it.  It  is  the  effect  of  the  unconditional  surrender  of 
the  consciousness  to  the  contrasting  ideas  that  have  long  assailed  it. 

All  the  associations  that  offer  resistance — that  is  to  say,  the 
products  of  true  fusion — we  judge  to  be  correspondent  with  reality, 
and  such  they  remain  from  the  moment  of  their  formation,  except 
as  regards  their  various  combinations  (vide  foregoing). 

Judgments  of  identity  are  always  formed  upon  these,  no  matter 
in  what  condition  they  may  be.  All  that  is  not  considered  to  be 

21 — 2 


324 


PSYCHIATRY 


true,  or  that  is  in  temporary  or  permanent  contradiction  to  the 
ideo-emotive  direction  of  the  personality,  is  vanquished  by  the 
concurrence  of  those  representations  that  tend  to  enlarge  the  net- 
work of  associations. 

Owing,  however,  to  specific  neurotic  predisposition,  such  associa- 
tions are  sometimes  formed  with  an  impulsiveness  of  representation 
that  is  peculiar  to  degenerates  (the  psychic  convulsibility  of  Fried- 
mann). 

There  are  always  certain  conditions  which  favour  the  formation 
of  primary  or  paranoic  deliria  in  degenerates.  An  emotional  state 
of  undue  intensity,  exaggerated  subjectivity  with  auto-observation 
maintained  in  activity  by  the  high  emotive  potential  (fear,  sus- 
picion, pride),  undue  force  and  impulsiveness  of  new  or  strange 
associations,  reduction  of  the  normal  associative  powers,  occasioning 
defect  of  criticism  and  acceptance  of  new  psychic  products  that 
do  not  correspond  with  reality,  concentration  of  the  apperception 
on  these  new  products,  and,  as  Del  Greco  well  says,  a weak  power 
of  defence  on  the  part  of  the  consciousness,  are  so  many  conditions 
favouring  the  formation  of  deliria. 

There  are,  therefore,  two  great  sources  of  deliria  : (i)  Altered 
associative  processes,  with  prevalence  of  ideas  of  contrast  ; (2)  the 
altered  perceptive  processes — illusions  and  hallucinations. 

As  regards  the  nature  of  their  ideative  content  we  distinguish  : 

(i)  Delirium  of  grandeur,  or  expansive  delirium.  Here  the  ideative 
process  is  altered  in  the  sense  that  the  subjects  consider  their  per- 
sonality, their  interests,  their  possessions,  and  their  relations  in 
the  external  world  under  the  aspect  of  grandiosity,  of  magnificence, 
and  of  power.  This  leads  to  expansivity.  The  ego  affirms  itself 
with  new  power,  new  aptitudes,  and,  gradually  expanding,  it  sur- 
passes all  its  neighbours  and  throws  itself  into  a world  of  the  most 
paradoxical  dreams. 

The  subject  has  a very  high  tone  of  feeling  about  his  own  per- 
sonality. Even  patients  who  have  long  been  timid  and  reserved, 
preoccupied  with  some  fancied  affection  of  the  heart,  lungs,  or 
stomach,  come  suddenly  to  feel  themselves  no  longer  ill  or  weak, 
but  unusually  well,  hyperbolically  healthy  and  strong,  capable  of 
meeting  every  difficulty  and  of  traversing  enormous  distances 
without  feeling  fatigued  ; feel  themselves,  in  a word,  to  be  endow'ed 
with  impossible  health  and  strength.  With  this  exalted  feeling  of 
the  physical  ego,  the  psychic  personality  becomes  transformed  or 
dissipated  in  proportion  as  it  departs  from  reality.  The  exalted 
sentiment  awakens  or  generates  analogous  ideas,  and  these  all  give 
rise  to  corresponding  conduct.  It  is  from  this  cause  that  such 
subjects  throw  themselves  without  consideration  into  strange  and 
niinous  undertakings,  and  abandon  themselves  to  a line  of  conduct 
that  is  in  every  way  new,  incoherent,  and  dangerous. 


PHYSIO-PATHOLOGY  OF  IDEATION 


325 


The  deliria,  truly  extravagant  dreams  that  henceforth  occupy 
and  transform  the  consciousness,  are  to  be  explained  according 
to  the  upbringing,  the  education,  the  conditions  of  life,  and  the 
inclination  to  a single  order  of  ideas  or  to  every  intellectual  pursuit. 
In  the  matter  of  wealth,  the  subjects  possess  hundreds  of  thousands 
of  pounds,  millions,  milliards,  etc.  ; they  have  ‘ ah  the  palaces  that 
line  a street  ’ ; ‘as  much  land  as  the  eye  takes  in  ’ ; ‘their  ships  furrow 
every  sea  ’ ; they  have  the  largest  diamonds,  the  most  precious  stones, 
etc.  With  regard  to  power  and  rank,  they  have  become  very  great 
Princes,  Ministers,  Kings,  Emperors,  or  they  belong  to  the  most  noble 
and  powerful  families  ; or,  again,  they  have  become  great  orators, 
masters  of  moving  and  fascinating  speech,  men  of  political  impor- 
tance. In  the  field  of  religion  they  become  reformers,  saints,  Messiahs, 
the  mother  of  God,  Christ,  God,  the  Lord  of  the  universe,  etc. 

It  is  very  evident  that  the  wealth  of  subjects  and  the  extent  of 
the  field  contributing  to  the  growth  of  the  delirium  vary  with  the 
degree  of  intellectual  development  and  culture  of  the  affected.  The 
delirium  of  an  imbecile  has  little  complication,  being  constituted 
of  a restricted  number  of  empty  ideas,  moving  in  a small,  mon- 
otonous and  colourless  circle  ; while  that  of  a fully-evolved,  and  still 
more  of  a cultured,  man  is  the  product  of  a number  of  notions  utilized 
in  a special  way  to  subserve  the  new  thesis.  It  is  further  to  be 
noted  that  in  weak-minded  persons  whose  intellectual  resources 
are  limited,  the  ideas  of  delirium  more  readily  resolve  themselves 
into  impulsive  and  violent  acts.  Serieux  and  Girondon  are  also 
agreed  upon  this  (‘  Caracteres  du  delire  dans  leurs  rapports  avec 
''intelligence  du  delirant  ’ — Arch,  de  Nevrologie,  1895). 

We  find  the  delirium  of  grandeur  in  maniacal  states,  in  which 
case  there  is  always  a great  superficiality  of  judgment  associated 
with  a very  active,  though  unco-ordinated  mnemonic  function,  and 
in  paralytic  dementia.  The  delirious  ideas  are  of  various  grades, 
extending  from  the  borders  of  probability  to  the  most  trivial  para- 
doxes, as  in  progressive  paralysis.  In  this  psychosis  the  mobility 
of  the  deliria  is  extreme  and  characteristic,  as  well  as  being 
paradoxical  in  nature.  The  paralytics  are  not  content  with  being 
only  very  rich,  but  pass  from  the  idea  of  wealth  to  that  of  power  and 
of  boundless  lordship.  Deliria  are  like  dreams — instantaneous 
representations  that  find  immediate  manifestation.  Sometimes 
they  are  rapid  in  their  evolution,  and  they  always  have  a character 
of  excessive  mobility  and  empty  illimitability. 

The  characters  of  mobility  and  illimitability  are  not,  however, 
always  present.  I have  not  infrequently  met  with  delirium  of 
grandeur  that  was  systematic  for  a long  period,  even  in  paralytics. 

Delirium  of  grandeur  may  be  primary,  systematic,  organized, 
and  in  such  cases  its  evolution  is  slow.  From  the  beginning  its 
germ  lies  in  the  psychic  personality,  then  it  plants  itself  as  an  embryo 
in  the  consciousness,  sprouting  and  developing  there,  until  it  covers 


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the  whole  of  consciousness  with  its  great  shadow,  and  finally 
transforms  it.  The  old  mental  organism  is  absorbed  and  digested 
by  the  system  of  delirium,  which  all  the  senses  slavishly  follow  and 
obey,  until  another  organism  is  outlined  with  the  notions  suggested 
by  the  delirious  ideas. 

The  delirious  idea  does  not  always  reach  the  stage  of  a com_plete 
ideo-emotive  system  that  gradually  substitutes  itself  for  the  old 
mental  organism,  for  in  some  cases  the  composition  of  the  psychic 
personality  is  preserved.  As  Friedmann  well  says,  some  deliria 
represent  nothing  more  than  the  exaggeration  of  normal  ideas. 
They  are  mild  formas  of  systematic  folly,  and  may  be  considered 
the  whims  of  a morbid  exaggeration  of  the  value  of  the  ego  in  its 
relations  with  the  external  world  ; or  they  are  the  products  of  the 
apperceptive  power  acting  upon  the  embryonic  delirious  idea  (Del 
Greco). 

Others,  again,  of  a logical  and  critical  nature,  will,  when  they 
become  delirious,  defend  their  assertions  by  argument,  thus  con- 
firming themselves  in  their  delirium,  and  they  may  still  be  able  to 
attend  to  their  business  or  employments  ; but  the  progressive 
transformation  of  the  personality  in  time  involves  them  exclusively 
in  the  new  system  of  false  ideas.  For  example,  Captain  X.  was 
unwilling  to  remain  among  those  ‘ who  never  did  anything  in  life,’ 
and  he  conceived  and  published  mad  projects,  such  as  the  idea 
of  putting  a great  globe  over  one  of  the  hills  of  Rome,  and  gather- 
ing under  it  all  the  museums  and  everything  grand  in  Rome,  and 
the  notion  that  he  was  the  man  who  could  avenge  the  disgrace  that 
a statesman  had  brought  upon  Apulia. 

Such  deliria  are  characteristic  of  paranoia,  in  which  they  are 
often  associated  with  ideas  of  persecution.  Sometimes,  and  oftener 
than  is  believed  by  many  alienists,  this  delirium  is  primary  and 
remains  isolated  for  a long  time.  The  youthful  student  at  the 
gymnasium  who  keeps  himself  apart  from  others  and  studies  in- 
tensely, with  the  purpose  and  conviction  of  becoming  a superior 
man,  although  his  labour  is  without  result,  shows  in  its  germ  the 
paranoic  delirium  of  the  young  adult  who,  after  long  research, 
believes  that  he  has  solved  the  problem  of  the  origin  of  misery  and 
pain,  and  finds  it  in  ‘ the  sperm  that  onanism  scatters  over  the  face 
of  the  earth.’  The  mystic  paranoic  has  a high  notion  of  himself, 
and  the  erotic  subject  is  a pretentious  and  often  persecuting  being. 
In  all  these  cases  the  delirium  of  megalomania  is  primary  and 
isolated  ; that  of  persecution,  if  it  be  developed,  is  secondary’  and 
often  late. 

The  delirium  of  grandeur  is  not  necessarily  the  successive  phase 
of  the  delirium  of  persecution.  The  latter  is  often  arrested  in  its 
development.  After  observing  200  cases  of  delirium  of  persecu- 
tion, Taty  and  Toy  found  megalomania  absent  in  32  per  cent.  One 
point  on  which  I cannot  agree  with  those  authors  is  that  the  primary 


PHYSIO-PATHOLOGY  OF  IDEATION 


327 


delirium  of  grandeur  is  a rare  and  inverted  form  of  paranoia,  to  be 
observed  solely  in  the  weak-minded.  In  Part  III.  of  this  work  I 
shall  show  how  frequent  primary  delirium  of  pride  is,  even  in  good 
mental  organisms.  Sometimes  it  'appears  also  in  old  persons  still 
possessing  all  their  faculties  (case  of  Ballet  and  Arnaud). 

The  delirium  of  grandeur  is  also  observed,  though  less  frequently, 
in  cases  of  alcoholic  insanity,  syphilitic  psychosis,  secondary  de- 
mentia, circular  insanity,  and  in  some  other  organic  diseases  of 
the  brain  ; sometimes  also  in  epileptic  insanity,  principally  when 
associated  with  religious  ideas.  In  this  last,  the  subject  has 
often  an  exaggerated  idea  of  his  own  capacity  and  aptitudes,  with 
impulsivity  and  liability  to  accessions  of  rage  when  contradicted 
in  his  ideas  of  his  own  importance. 

2.  Depressive  delirium,  of  which,  again,  we  distinguish  several 
sub-species  : 

[a)  The  delirium  of  melancholia,  properly  so-called.  This  form 
is  never  primary,  but  always  secondary  to  a painful  affective  state 
of  mind.  In  such  a case  the  delirium  constitutes  itself  out  of 
associations  of  an  afflicting  nature.  Insignificant  events  of 
past  life,  to  which  no  importance  had  previously  been  attached, 
assum.e  the  utmost  importance,  and  are  recognised  as  the  cause  of 
the  intense  sufferings.  An  error,  such  as  is  committed  by  every- 
body, gives  the  melancholic  subject  occasion  to  formulate  the 
judgment  that  he  has  been  incapable  of  doing  anything  at  all,  that 
he  has  ruined  his  affairs,  and  has  therefore  become  wretched  ; that 
he  can  do  nothing  now,  that  his  ruin  is  irremediable,  and  all  through 
his  own  fault.  The  illness  or  the  loss  of  an  infant  makes  the  melan- 
cholic mother  think  that  she  has  been  lacking  in  care,  that  she  has 
been  the  cause  of  the  death  of  her  own  child,  that  she  has  been  a 
woman  negligent  of  her  proper  duties,  an  unnatural  mother.  Another 
person  who  may  have  had  to  take  an  oath  believes  that  he  has 
rendered  himself  guilty  of  perjury.  A faithful  woman  believes 
herself  an  adulteress,  merely  because  she  has  received  an  honest 
courtesy  from  another  man. 

These  deliria  may  remain  as  they  originate  or  they  may  generate 
other  deliria,  according  to  upbringing,  education,  and  the  formative 
power  of  the  mind.  Once  the  melancholic  subjects  have  judged 
themselves  culpable,  they  complete  their  delirium  by  the  formation 
and  the  association  of  another  logical  group  of  ideas,  such  as  the  idea 
of  expiation,  and  so  some  come  to  believe  themselves  ‘ condemned  to 
penal  servitude  for  life,’  or  ‘ just  going  to  be  hanged  others  that 
they  are  ‘ accursed  persons  possessed  by  the  evil  spirit  ’ (demono- 
melancholia) ; others,  again,  believe  themselves  the  victims  of 
witchcraft  and  of  persecution  by  gods  or  human  beings  (secondary 
delirium  of  persecution). 

The  delirium  of  self-accusation  is  met  with  also  in  progressive 


328 


PSYCHIATRY 


paralysis  (E.  Rossi).  In  this  affection,  indeed,  we  find  every  form 
of  delirium  without  exception,  and  without  any  special  significance, 
since  they  all  germinate  on  the  barren  soil  of  dementia.  It  is  also 
met  with,  although  very  rarely,  in  some  forms  of  paranoia,  in  which 
the  subjects  hold  firmly  to  their  delusions,  and  yet  have  no  feeling 
of  resignation.  According  to  Seglas,  the  delirium  of  self-accusation 
is  sometimes  systematized  in  subjects  hereditarily  afflicted  and 
unbalanced,  in  whom  we  find  mingled  pride,  egoism,  timidity,  and 
diffidence.  It  presents  itself  as  a system  constituted  of  delirious 
interpretations  applied  to  past  and  present  life,  and  has  not  the 
fixity  of  true  melancholic  delirium.  Remissions  occur  with  re- 
mission of  the  moral  suffering  in  these  cases,  or  else  it  assumes  a 
stereotyped  form  ; or,  again,  there  arise  ideas  of  grandeur  and  of 
persecution  with  which  the  delirium  associates  itself  or  alternates, 
and  in  this  case  it  is  an  exaggeration  of  the  natural  character 
of  these  subjets.  I must  warn  my  readers,  with  regard  to  the 
diagnosis,  that,  when  the  delirium  of  self-accusation  or  any  other 
depressive  delirium  is  associated  with  the  delirium  of  grandeur, 
we  have  often  to  deal  with  dementia  paralytica  in  course  of 
evolution. 

{h)  The  delirium  of  metamorphosis,  or  transformation  into  some 
form  of  animal  (lycanthropy).  This  form  is  met  with  much  more 
rarely  to-day  than  in  past  centuries,  including  even  the  first  half 
of  the  nineteenth  century.  I have  observed  only  one  case,  which 
occurred  a few  years  ago. 

(c)  Delirium  of  Negation. — Depressive  delirium  may  reach  a 
very  high  stage  in  the  negation  of  everything.  In  these  cases  the 
sufferers  affirm  that  ‘ they  have  no  longer  any  family,’  ‘ they  have 
no  longer  anything,’  ‘ everything  is  lost,’  ‘ the  city  is  deserted  of 
men  ; indeed,  none  are  left  alive,’  ‘ the  heart  no  longer  beats,  and 
the  blood  has  ceased  to  circulate.’  As  in  the  case  of  the  lady  I 
mentioned  before,  such  delirium  reaches  the  complete  negation  of 
the  personality. 

Cotard  and  others  have  assigned  undue  importance  to  the 
delirium  of  negation,  attributing  to  it  certain  clinical  characters, 
many  of  which,  as  a matter  of  fact,  are  common  to  the  majority  of 
cases  of  depressive  delirium,  such  as  self-accusation  and  hypo- 
chondria, of  which  it  represents  a more  advanced  stage  of 
evolution. 

Only  one  of  the  deliria  of  negation,  the  h^^pochondriacal,  has 
the  significance  that  the  Italian  observers,  Obici  Osservazioni 
nosologiche  cliniche  sul  cosi  detto  “ delirio  di  negazione,"'  ’ Riv. 
Sper.  di  Fren.,  vol.  xxvi.)  and  S.  De  Sanctis  (‘  Psicopatologia  delle 
idee  di  negazione,'  II  Manicomio,  1900)  have  attributed  to  it, 
departing  far  from  the  ideas  of  Cotard.  When  the  evolution  of 
li33)ochondriacal  delirium  has  reached  such  a point  that  the  sufferer 
asserts  that  he  has  no  longer  an\^  stomach,  an\^  head,  3.ny  organs. 


PHYSIO-PATHOLOGY  OF  IDEATION 


329 


then  there  generally  exists  a basis  of  senile  involution  or  other 
degenerative  process,  and  we  can  no  longer  speak  of  psychoneiirotic 
melancholia. 

These  ideas  arise  either  through  the  evolution  of  pre-existing 
delirious  ideas  or  concomitantly  with  such  ideas  and  without  any 
evident  nexus  therewith.  I have  observed  this  many  times  in 
senile  melancholia  and  in  progressive  paralysis.  Sometimes  they 
arise  even  in  young  people,  owing  to  the  evolution  of  hypochon- 
driacal paranoia.  They  often  make  their  appearance  in  the  acute 
psychopathies  due  to  intoxication  and  accompanied  by  hallucina- 
tory mental  confusion. 

"in  many  of  these  cases  there  has  been  a precedent  negational 
constitution,  a fact  that  has  also  been  observed  by  De  Sanctis. 

If  the  delirium  of  negation  be  considered  in  a wide  sense,  as  it 
seems  to  me  it  must  be  considered,  and  not  merely  within  the  limits 
of  hypochondriacal  delirium  of  negation,  it  is  met  with  in  very  varied 
psychopathies  : in  melancholia,  in  mental  confusion,  in  progressive 
paralysis,  and  in  senile  dementia.  In  melancholia  it  may  be  the 
first  delirium,  and  is  then  sometimes  substituted  by  others,  or  the 
final  delirium,  which  often  becomes  stereotyped.  Whatever  be 
the  clinical  form,  the  delirium  is  the  chief  manifestation,  and  re- 
covery depends  not  only  on  the  particular  form  of  dehrium,  but 
also  on  the  most  varied  contingencies  and  conditions,  intrinsic  or 
extrinsic  to  the  patient. 

The  delirium  of  negation  of  varied  content — if  we  make  excep- 
tion of  the  hypochondriacal — is  quite  as  significant  as  any  other 
delirium  of  depression.  Like  that  of  self-accusation,  it  germinates 
most  easily  on  hereditary  soil,  and  in  the  germ  we  find  it  associated 
with  all  the  painful  or  afflictive  states  of  mind,  including  the  physio- 
logical. In  the  struggle  for  existence,  want  of  success,  discomfort, 
discouragement,  are  accompanied  by  ideas  of  negation.  The  poets, 
in  whom  the  afflictive  tone  predominates,  have  manifested 
ideas  of  negation,  or  have  put  them  into  the  mouths  of  their 
characters. 

Leopardi  in  his  greatest  affliction  enunciates  the  most  solemn 
negation  when  he  says  : 

‘ A noi  presso  la  culla 
Immoto  siede,  e su  la  tomba,  il  nulla.’ 

‘ Beside  our  cradle  sits  unmoved,  and  on  our  tomb,  nothing.’ 

And  again : 

‘ Ecco  tutto  e simile,  e discoprendo 
Solo  il  nulla  s’accresce.’ 

‘ Listen ; all  is  alike,  and  by  our  discoveries  we  only  add  to  nothingness,* 

Ugo  Foscolo,  the  immortal  poet  of  the  tombs  (‘  I Sepolcri  ’), 
was  also  of  a melancholic  type,  and  expresses  ideas  of  negation  with 


330 


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regard  to  the  highest  affirmation  of  Nature  when  he  says  in  his  poem 
to  the  sun  : 

‘ Ma  tu  giammai,  eterna  lampa,  non  ti  cangi  ? Mai  ? . . . 

Pnr  verra  di  che  nell’  antique  voto  cadrai  del  nulla.  . . 

‘ But  dost  thou  never  change,  eternal  lamp  ? Never  ? . . . 

This  will  be  for  that  in  the  ancient  void  thou  wilt  have  come  from  nothing.’ 

Shakespeare  represents  the  negational  type  in  Hamlet  when  he 
makes  him  say  : 

‘ . And  indeed  it  goes  so  heavily  with  my  disposition  that  this  goodly 

frame,  the  earth,  seems  to  me  a sterile  promontory ; this  most  excellent 
canopy,  the  air,  look  you,  this  brave  o’erhanging  firmament,  this  majestical 
roof  fretted  with  golden  fire,  why,  it  appears  no  other  thing  to  me  but  a foul 
and  pestilent  congregation  of  vapours.’ 

Goethe,  speaking  of  the  genius  of  evil,  calls  him  Negation  : 

‘ Ich  bin  der  Geist  der  stets  verneint  . . . 

So  ist  dann  alles  was  ihr  Siinde, 

Zerstorung,  kurz  das  bose  nennt, 

Mein  eigentliches  Element.’ 

‘ I am  the  Spirit  that  denies  everything  ; and  so  all  that  you  call  sin  and 
destruction — in  short.  Evil — is  my  proper  element.’ 

Pain,  weakness,  negation,  are  three  indivisible  terms,  three 
aspects  under  which  we  may  consider  a state  of  mind  that  passes 
by  infinite  degrees  from  the  physiological  episode  to  the  most 
intense  melancholy,  in  which  negation  reaches  lycanthropy,  meta- 
bolism of  the  proper  personality,  or  the  complete  negation  of  one’s 
proper  existence,  that  under  another  form  expresses  itself  in  suicide. 

The  woman  who  denied  her  own  existence,  failing  to  recognise 
her  own  identity,  recovered  completely  after  almost  three  years  of 
this  stereotyped  delirium,  although  she  belonged  to  a family  in 
which  three  other  sisters  were  epileptics  and  one  a morphinomaniac. 
We  can  draw  no  sure  criterion  for  the  prognosis  from  the  contents 
of  such  depressive  deliria,  nor  can  we  agree  unconditionally  to  the 
distinction  between  ideas  of  negation  and  delirium  of  negation, 
s\"stematized  or  not  (Seglas).  These  deliria,  like  all  others,  are 
nothing  but  preformations  of  badly-organized  minds  (degenera- 
tion) that  have  been  repelled  by  ideas  better  answering  to  reality  ; 
they  are  often  the  episodic  or  the  systematic  exaggeration  of  normal 
ideas,  and  may  be  met  with  in  many  psychopathic  states  (Camuset 
and  others). 

The  S3^stematization  depends  upon  conditions  extrinsic  to  the 
genesis  of  the  delirium  itself. 

In  the  formation  of  hypochondriacal  delirium  of  negation  we 
generally  find  gradation  of  intensity  of  the  delirious  ideas,  be  they 
primary  or  secondaiy.  It  begins  often  with  a vague  apprehension 


PHYSIO-PATHOLOGY  OF  IDEATION 


331 


as  to  personal  health  (kinaesthetic  emotivity),  and  as  this  increases 
it  puts  the  mind  into  an  orgasm.  The  imminent  danger  to  his 
health,  ‘ already  in  a very  bad  way,’  absorbs  all  the  interest  of  the 
subject,  who  later  on  interprets  in  the  light  of  the  besetting  idea, 
those  new  sensations  that  either  arise  directly  from  the  cerebral 
malady  that  has  altered  the  mode  of  feeling  of  the  somatic  ego,  or 
are  derived  from  the  concentration  of  attention  on  those  parts  of 
the  body  that  are  believed  to  be  suffering  (peripheral  projection  of 

the  preperception).  ^ 

Gradually  the  delirium  takes  the  form  that  ‘ a serious  illness, 
which  the  sufferer  often  does  not  specify,  ‘ will  carry  him  off  m a 
short  time,’  or  that  ‘ some  organ  or  other  is  in  course  of  destruction 
— is  almost  consumed,  or  is  putrefied,’  etc. 

‘ Nothing  will  pass  down  my  throat  ’ ; ‘ nothing  can  enter  my 
stomach,  which  is  closed  ‘ my  anus  is  blocked  up’;  ‘ my  body  is 
already  putrefying — I can  even  perceive  the  corpse-like  sm.ell  ‘ my 

arm  has  turned  into  wax  ’;  ‘ my  heart  no  longer  beats  ; I am 
impotent,  for  my  penis — which  was  perfectly  developed  has  become 
as  thin  as  a goose-quill.’  These  are  examples  of  hypochondriacal 
delirium  of  negation  and  metabolic  delirium.  This  sometimes 
reaches  the  same  height  of  absurdity  as  the  deliiium  of  grandeui 
in  progressive  paralysis,  when  the  subjects  declare  that  they  have 
no  stomach  or  no  anus,  even  though  they  eat  or  are  fed  with  the 
stomach-tube,  and  evacuate  the  intestines  regularly. 

The  succession  of  the  phases  of  hypochondriacal  deliiium,  fiom 
simple  preoccupation  about  personal  health  (hypochondriasis)  to 
hypochondria  with  delirium  of  negation,  has  been  noted  by  Ball, 
Ritti,  Vallon,  Marie,  Cotard,  Castin,  and  others.  Such  delirium, 
however,  is  not  very  frequent,  nor  is  it  so  systematic  as  some  have 
affirmed  : and  the  ideas  of  negation  do  not  always  arise  in  the 
last  phase  of  chronic  hypochondriacal  delirium,  as  is  maintained  by 
Cotard.  Sometimes  the  hypochondriacal  delirium  is  not  isolated, 
but  is  associated  with  other  delirious  ideas  of  persecution  and  of 
self-accusation. 

Hypochondriacal  delirium  has  its  roots  in  a perversion  of  the 
kinsesthetic  sense,  and  may  be  considered  as  essentially  a malady 
of  the  somaesthetic  zone. 

{d)  The  Delirium  of  Persecution. — This  form  is  more  frequent 
to-day  than  in  past  times,  and  the  persecution  is  by  human  beings, 
whereas  formerly  it  was  by  supernatural  beings.  As  a rule,  it  is 
the  principal  factor  on  which  the  whole  psychopathy  turns,  but  it 
is  frequently  met  with  episodically  in  almost  all  psychopathies, 
even  in  mania  and  in  progressive  paralysis.  In  these  cases  it  is 
more  or  less  fugitive,  and  sometimes  it  is  provoked. 

This  delirium  consists  essentially  in  the  fact  that  the  individual 
affected  believes  that  he  is  the  object  of  persecution  on  the  part 
of  others,  and  in  the  external  world  he  has  false  perceptions,  not 


332 


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only  of  the  danger  threatening  his  person,  his  honour,  or  his  interests, 
but  also  of  the  means  by  which  it  is  sought  to  offend  or  to  destroy 
him,  and  sometimes  even  of  the  persons  who  are  im.placably  con- 
spiring and  working  against  him.  This  delirium  once  confirmed, 
whether  it  be  secondary  or  primary,  furnishes  the  subject  with  a 
notion  that  is  intensified  by  the  products  of  the  misinterpreted 
sensations  that  develop  sooner  or  later  with  the  delirium.  In 
delirium,  illusions  and  hallucinations  have  the  same  value  as  an- 
alogous perceptions  furnished  by  observation  have  in  normal 
ideation. 

For  example,  the  delirious  subject,  who  considers  his  honest 
wife  an  adulteress,  reads  the  signs  of  treachery  in  her  attitude,  her 
looks,  even  in  her  caresses,  and  finds  in  all  of  these,  snares  that  she 
is  laying  for  him  (illusory  preperception).  For  hours  he  paces  to  and 
fro  before  the  door  of  the  bedroom  in  which  the  unhappy  woman 
is  shut,  and  peers  through  the  keyhole  ; when  he  goes  away  he  puts 
marks  on  the  door  to  assure  himself  that  it  has  not  been  opened 
during  his  absence.  With  threats  he  examines  her  genitals  to  find 
traces  of  a recent  embrace.  He  watches  through  the  night,  and 
in  the  noises  that  his  exalted  sensory  centres  make  him  hear,  he 
finds  irrefragable  proof  of  the  wrong  done  him  by  his  infamous  con- 
sort, who  permits  her  gallant  to  penetrate  into  the  nuptial  chamber 
in  his  very  presence. 

Other  subjects  feel  that  they  are  the  objects  of  troublesome 
attentions  on  the  part  of  outsiders ; ‘ a watch  is  put  upon  them  in 
order  to  spy  out  anything  that  may  be  censurable  in  their  conduct  : 
they  are  no  longer  treated  with  the  same  goodwill  as  before.’  Every- 
thing around  the  subject  assumes  an  attitude  of  hostility  to  him. 
At  first  he  only  suspects  that  others  wish  to  do  him  harm,  but  his 
illusions  become  confirmed  and  give  him  matter  for  false  conclu- 
sions— e.g.,  an  article  or  an  innocent  advertisement  in  a newspaper 
is  a taunt  or  an  accusation  ; the  priest  is  alluding  to  him  in  his 
sermon,  etc. 

Others  believe  that  their  minds  can  be  read  and  that  their 
most  secret  thoughts  have  become  public  property.  The  gestures 
and  the  attitudes  of  the  people  they  meet  are  all  against  them  : 
they  have  become  butts  for  taunts  and  mockery  ; coughing  or 
spitting  is  an  insult  meant  for  them  ; the  contents  of  a speech  are 
an  offence  to  their  politics  or  their  religion,  etc.  They  no  longer 
feel  secure  either  at  home  or  in  the  streets,  and  they  are  always 
suspicious,  restless,  and  sleepless.  At  last  they  come  into  pos- 
session of  irrefragable  proof  that  they  are  victims  of  the  darkest 
malefactions,  and  this  they  know  directly.  Enemies  are  lying  in 
wait  for  them  with  the  basest  arts.  If  these  enemies  are  not  special 
persons,  they  are  associations  or  corporations,  such  as  the  pohce, 
the  Freemasons,  the  Jesuits,  the  Socialists,  etc.,  and  they  employ 
the  telephone,  electricity,  or  "poison,  which  they  find  means  of 


PHYSIO-PATHOLOGY  OF  IDEATION 


333 


administering  in  food,  water,  or  in  the  very  air  that  is  breathed. 
If,  meanwhile,  hallucinations  supervene,  always  homologous  with 
the  contents  of  the  ideas  of  delirium,  the  delirium  reaches  its  acme, 
the  constitution  of  the  primary  personality  is  more  or  less  dis- 
arranged, and  a new  direction  is  impressed  on  the  whole  psychic 
life  of  the  subject,  who  either  is  fatally  influenced  by  the  idea  of 
persecution  and  poses  as  a victim,  in  a depressed  state  of  mind,  or 
he  turns  upon  his  presumed  persecutors,  denounces  them,  and  runs 
off  to  lay  an  accusation  against  them  before  the  Public  Prosecutor  ; 
or  his  resentment  takes  a violent  form,  and  he  does  justice  with 
his  own  hands  against  his  presumed  enemies,  the  persecuted  be- 
coming persecutor. 

Bruni,  at  whose  trial  for  the  murder  of  Marquis  Berardi,  in  the 
provincial  asylum  at  Rome,  I gave  expert  evidence — believed  that 
he  was  persecuted  by  a widely-extended  antihumanitarian  sect,  of 
which  he  declared  Crispi  to  be  the  head.  Beiardi  was  chairman  of 
the  asylum  board  of  directors,  and  his  haughty  and  authoritative 
proceedings  during  his  visits  of  inspection  of  the  asylum  buildings 
led  Bruni  to  argue  that  the  Marquis  belonged  to  that  sect.  As 
soon  as  the  Marquis  came  within  reach,  Bruni  dealt  him  a pre- 
meditated blow  on  the  back  of  the  head  with  an  iron  rod,  felling 
him  to  the  ground.  This  is  an  example  of  the  persecuted  turned 
persecutor.  I am  inclined  to  admit  the  two  types  well  defined  by 
Falret  and  Lasegue — Falret’s  type  of  reasoning  persecuted  subjects, 
who  almost  never  show  hallucination  in  the  long  course  of  the 
malady,*  and  Lasegue’s  type  of  persecuted  subjects  with  hallucina- 
tions. The  first,  much  less  numerous  than  the  second,  are  not  very 
dangerous,  and  at  most  they  are  dangerous  only  to  the  persons  con- 
nected with  the  event  that  is  the  basis  of  their  delirium.  As  a rule, 
they  are  rather  troublesome  than  dangerous  ; they  prefer  to  write 
and  to  denounce  their  persecutors  rather  than  to  execute  justice 
with  their  own  hands.  The  subjects  with  hallucinations  are  much 
more  dangerous,  and  to  a much  wider  circle  of  persons,  according 
to  the  nature,  the  content,  and  the  vividness  of  the  hallucinations. 

These  hallucinations  arise  very  early,  long  before  the  delirium 
is  organized — that  is  to  sa,y,  in  the  period  of  unconscious  prepara- 
tion, when  the  affective  tone  of  the  mind  is  altered.  In  such  cases 
the  evolution  of  the  delirium  is  rapid,  because  the  hallucinations 
furnish  the  system  of  delirium  with  ready  objective  proofs — the 
subjective  perceptions.  The  hallucinations,  however,  may  arise  at 
a more  advanced  evolution  of  the  system  of  delirium,  which  is  fed 
by  simple  illusions. 

In  general,  therefore,  the  delirium  of  persecution,  like  every 
other  variety  of  delirium,  besides  being  substantially  constituted 
of  a qualitative  disturbance  of  ideation,  is  ordinarily  associated 

* Cases  of  late  hallucinations  of  Falret’s  type  are  not  rare  ; one  has 
been  published  by  Vallon. 


334 


PSYCHIATRY 


with  other  disturbances  of  the  more  elementary  activities  of  the 
mind,  such  as  an  emotive  state  with  a particular  trend,  the  disturb- 
ance of  association  already  mentioned,  and  sensory  disorders. 
Often  the  illusions  and  hallucinations  that  confirm  the  individual 
more  and  more  in  the  false  notion  he  has  conceived  concur  in  the 
more  rapid  and  certain  transformation  of  the  primitive  personality 
into  another  that  is  more  substantially  constituted  of  groups  of 
false  ideas. 

5.  Another  delirium,  apparently  depressive,  but  in  substance 
expansive,  is  the  religious  delirium,  to-day  much  less  frequent  than 
it  was  in  the  past.  The  majority  of  its  subjects  are  timid,  proud, 
poor  in  spirit,  and  resigned,  and  they  have  a strong  inclination  to 
religious  practices,  often  accompanied  by  ostentatious  vanity. 
They  are  enthusiasts,  one-sided  individuals,  fanatics.  Two  factors 
concur  to  a very  great  extent  in  the  development  of  this  delirium— 
the  diminution  of  the  apperceptive  power  over  reality,  and  the 
mystic  encumbrance  of  the  mind,  increased  by  reading  sacred  books, 
by  concentration  of  the  mind  on  doctrines,  dogmas,  and  religious 
ideas,  and  by  impoverishment  of  the  blood  and  the  entire  organism 
through  repeated  fasts,  prolonged  vigils,  penances,  discipline,  and 
other  rigours  of  religious  life,  and  frequently  onanism.  These  are 
aided  by  misfortunes,  by  disappointment  in  love,  and  by  preaching 
that  exalts  the  fancy  of  the  believers.  On  a soil  thus  prepared  the 
delirium  arises,  either  primarily  or  preceded  by  illusions  or  hallucina- 
tions of  a religious  character. 

The  sufferer  commences  by  supposing  that  his  fasts,  his  chastity, 
and  his  penances  will  free  him  from  all  traces  of  the  earthly,  and 
that  he,  thus  purified,  will  be  taken  into  particular  consideration 
by  the  Almighty.  Thereafter  begin  the  sensory  disturbances,  with 
which  he  completes  the  false  concept  by  way  of  association.  He 
imagines  that  a high  religious  mission  has  been  reserved  for  him, 
and  that  a great  reward  will  be  decreed  him  by  Heaven  for  his 
irreproachable  conduct.  From  this  simple  supposition  the  delirium 
is  concreted  and  takes  consistency,  because  the  subject,  without 
reflection,  and  impelled  by  illusions  and  even  hallucinations,  accepts 
the  idea  that  he  is  an  apostle  of  the  Word  of  God,  a prophet,  a saint, 
and  reformer.  Great  powers  have  been  conferred  upon  him,  and 
henceforth  he  is  freed  fiom  the  cares  of  the  common  life,  his  high 
duty  being  to  convert  the  unbelieving  and  to  reform  the  world. 
From  this  stage  the  young  apostle  gradually  becomes  the  saviour 
of  the  world,  and  the  illuminated  young  woman  the  mother  of  God. 

Such  religious  delirium  is  often  found  episodically  in  the  acute 
sensory  phrenopathies,  and  then  has  its  origin  in  primary  hallucina- 
tions, like  the  delirium  of  persecution.  It  is  found  also  in  a fugi- 
tive form  in  alcoholic  and  in  epileptic  insanity  (Mobille).  Some- 
times it  assumes  the  character  of  what  Prouvost  has  called  prophetic 
delirium,  which  is  hallucinatory  and  quite  distinct  from  the  belief — 


PHYSIO-PATHOLOGY  OF  IDEATION 


335 


common  to  all  peoples  and  to  all  religions — in  the  possibilit}^  of 
communicating  with  supernatural  beings,  benevolent  or  malignant, 
who  give  warning  of  future  events  through  such  media.  We  can 
distinguish  vesanic  prophetic  delirium,  which  is  found  more  or  less 
stereotyped  in  almost  all  forms  of  insanity  based  on  degeneration, 
from  hysterical  prophetic  delirium,  which  is  more  typical  and  some- 
times epidemic.  I have  frequently  met  with  it  in  the  hallucinatory 
terminal  phase  of  the  grand  attack  of  typical  hysteria. 

Systematized  deliria  either  transform  the  whole  personality,  the 
mental  patrimony  undergoing  the  phagocytic  action  of  the  delirium 
and  becoming  assimilated  by  the  predominating  false  idea,  or  their 
assimilative  power  does  not  extend  over  the  whole  mental  patri- 
mony of  the  personality,  which,  although  it  assumes  the  particular 
cast  impressed  upon  it  by  the  false  content  of  consciousness,  yet 
has  still  at  command  for  the  normal  government  of  life  a larger  or 
smaller  portion  of  its  former  acquisitions. 

These  various  forms  of  delirium,  of  whatever  origin,  may  succeed 
one  another,  may  be  confused,  and  may  coexist.  The  megalo- 
maniac who  meets  with  derision,  and  who  notes  that  not  one  of  his 
ideas  finds  acceptance,  and  that  not  one  of  his  projects  is  carried 
out,  draws  therefrom  the  inference  that  envy  is  raising  up  enemies 
against  him,  and  is  planning  all  manner  of  evil  to  do  him  injury 
(consecutive  delirium  of  persecution). 

On  the  other  hand,  through  association  by  contrast,  the  perse- 
cuted subject  convinces  himself  that  the  persecution  of  which  he 
is  a victim  has  its  raison  THre  in  the  fact  that  someone  has  an 
interest  in  wounding  his  honour,  in  humiliating  him,  because  he 
has  superior  qualities  that  throw  the  qualities  of  others  into  the 
shade. 

The  same  thing  happens  with  religious  delirium,  which  is  often 
a mixture  of  delirious  ideas  of  religion,  grandeur,  and  persecution. 
Sometimes  the  delirious  ideas  are  of  diverse  content  from  the 
beginning,  and  in  such  a case  the  delirium  is  indeterminate.  There 
is  always  present  an  anomalous  emotional  state  of  fear  and  pride, 
and  it  is  by  the  predominance  of  one  of  these  two  emotions  over 
the  other  that  persecuted  subjects  are  distinguished  as  humble  or 
frond.  The  humble  submit  to  the  persecution,  do  not  offer  to 
take  the  offensive,  and  have  a tendency  to  suicide,  in  order  to 
escape  the  persecution.  They  show  gradations,  and  the  first  in 
the  series  are  plainly  paranoic,  while  the  last  tend  to  confound 
themselves  with  the  melancholic.  The  proud  are  generally  aggres- 
sive. 

All  these  paranoic  deliria  grow  in  a soil  of  degeneration.  On 
this  point  we  may  agree  with  Rene  Semelaigne,  who  refuses  to 
admit  a chronic  delirium  (Magnan)  distinct  from  the  delirium  of 
degenerates.  Further,  the  chronic  deliria  of  persecution  of  neuras- 


336 


PSYCHIATRY 


thenics,  who  are  curable,  are  developed  on  the  degenerative  neuras- 
thenic base,  often  through  hereditary  taint. 

The  other  varieties  of  persecuted  subjects,  the  alcoholic,  those 
of  the  climacteric  period,  the  senile  in  all  their  varieties — the  jealous, 
the  litigious  and  querulous,  the  revengeful  (Cullerre),  the  erotic,  all 
more  or  less  criminal — and  the  cases  conforming  to  no  type  (Ballet), 
the  paranoics  in  general,  it  will  be  more  convenient  for  us  to  con- 
sider in  the  third  part  of  this  work. 

Here,  however,  I must  not  fail  to  call  attention  to  a form  of 
systematized  delirium  that  is  clearly  hallucinatory.  There  exist 
two  varieties  of  it.  One  comprises  cases  in  which  hallucinations 
of  one  or  more  senses  are  repeated  in  a uniform  manner,  determin- 
ing a range  of  false  thoughts  that  are  rapidly  systematized  ; of  this 
variety  acute  (curable)  and  chronic  cases  occur.  The  other  variety 
comprises  cases  in  which  there  has  been  a precedent  sensory  delirium, 
but  the  hallucinations  that  prevailed  in  the  course  of  the  phrenosis 
remain  as  a residuum,  with  the  corresponding  delirium,  which  is 
systematized  as  in  the  primary  delirium,  and  is  susceptible  of  a slow 
cure  (Lojacono  and  Angiolella’s  cases). 

From  what  has  been  hitherto  said,  it  will  be  easily  understood 
how  some  authors  have  come  to  speak  of  partial  deliria  and  of 
general  and  total  deliria.  The  delirium  is  general  either  when  the 
whole  ideation  is  altered,  so  that  everything  is  falsified  and  thrown 
into  disorder,  or  when  a single  group  of  delirious  ideas  has  left  a 
good  part  of  the  field  of  ideation  in  sound  relation  to  the  external 
world  for  a certain  time,  but  has  gradually  absorbed  everything, 
and  assimilated  the  ideative  content  of  the  old  personality,  finally 
overturning  the  whole  perceptive  process  in  order  to  make  way  for 
itself. 

Even  though  we  accept  the  term  ‘ partial  delirium,’  it  is  not 
difficult  to  see  that  this  is  not  what  it  would  appear  to  be  after  a 
superficial  analysis  ; that  besides  those  false  ideas  that  manifest 
themselves  most  readily,  there  exist  others  more  latent ; and  that 
the  whole  mental  life  in  its  diverse  manifestations  is  affected  by  the 
partial  transformation  of  the  personality. 

There  exist,  also,  forms  of  generalized  delirium,  usually  hallu- 
cinatory, attended  by  obscuration  of  the  consciousness  (Francotte), 
with  loss  of  the  notion  of  time,  place,  and  persons.  These  forms 
correspond  to  the  hallucinatory  mental  confusion  described  by 
Chaslin,  to  some  forms  of  sensory  phrenosis  (Bianchi),  to  the  acute 
sensory  delirium  of  Krafft-Ebing,  and  to  the  ‘ Verworrenheit  ’ of 
the  Germans.  Such  deliria  are  always  toxic,  if  acute,  and  they 
have  their  counterpart  in  the  initial  deliria  of  typhoid  fever,  as 
described  by  Aschaffenburg. 

One  variety  of  generalized  delirium  we  have  in  those  cases  that 
Pichon,  confirming  the  opinion  of  Regis,  calls  ‘ deliria  oneirica,’  or 
deliria  of  dreams.  These  deliria  are  constituted  of  scenes  from 


PHYSIO-PATHOLOGY  OF  IDEATION 


337 


dreams,  changing,  varied,  and  uninterrupted,  the  subject  being  aS 
if  he  were  in  a somnambulic  dream.  These  occur  generally  at  night, 
but  sometimes  they  continue  after  waking.  On  recovery,  the 
patient  has  no  recollection  of  his  delirium.  These  cases,  like 
the  other  variety  of  acute  generalized  delirium,  are  of  toxic 
origin. 

With  regard  to  their  origin,  deiiria  are  divided  into  primary  and 
secondary.  Primary  deliria  are  represented  by  anomalous  ideative 
associations,  not  preceded  by  an  affective  condition  of  the  mind, 
depressed  or  exalted,  as  in  melancholia  and  maniacal  states,  nor  by 
sensory  disturbances — illusions  or  hallucinations.  In  this  case  the 
profound  alteration  of  feeling  and  the  sensory  disturbances  follow 
the  appearance  of  the  delirium,  which  announces  itself  in  con- 
sciousness as  a new  affirmation.  In  the  adult  mental  organism  its 
germ  represents  what  an  embryonic  histological  element,  that  had 
its  hierarchic  biological  position  assigned  to  it  in  the  genesis  of  the 
organs,  represents  in  the  midst  of  tissues  that  have  become 
specialized.  Here  the  embryonic  dement  lives,  but  it  lies  latent, 
and  does  not  disturb  the  life  of  the  organ  in  which  it  is  lodged  until 
it  finds  favourable  conditions  for  development,  when  it  gives  rise 
to  carcinoma  or  sarcoma,  which  invades  or  gradually  substitutes 
itself  for  the  organ  in  which  it  is  developed,  threatening  the  life  not 
only  of  that  part,  but  even  of  the  whole  organism. 

The  greater  number  of  primary  deliria,  as  also  of  secondary 
deliria,  contain  a nucleus  that  has  belonged  to  the  mental  organism 
in  one  phase  of  its  evolution.  In  the  actual  mental  organism  those 
nuclei  represent  true  embryonic  elements,  to  which  sometimes  cor- 
respond modes  of  speech  that  have  their  counterpart  in  the  language 
of  past  generations  or  in  that  of  childhood.  These  are  the  neolo- 
gisms (Tanzi). 

It  is  much  discussed  whether  there  is  not  a precedent  particular 
emotive  state  in  all  these  cases,  and  for  my  part  I agree  with  De 
Montyel(‘D^  la  genese  des  conceptions  delirantes,'"  etc..  Gazette  des 
Hopitaux,  1900)  that  the  anomaly  of  kinaisthesis  is  the  main  factor 
in  systematized  deliria.  The  emotional  tone  is  the  true  field  on 
which  deliria  germinate.  These  deliria,  which  are  resultants  of 
allegoric  representations,  are  a secondary  phenomenon,  due  to 
association  between  emotional  states  and  ideas. 

If  we  wish  to  be  strictly  accurate,  we  ought  to  say  that  all 
deliria  are  secondary,  only  it  is  well  to  add  that  in  the  primary  the 
emotional  state  is  less  evident  and  less  intense. 

Secondary  deliria  are  generated  by  abnormal  affective  states, 
painful  or  exalted,  or  else  by  sensory  disturbances.  In  the  first 
case  the  delirium  develops  through  association  of  ideas  correspond- 
ing to  the  predominating  emotion.  In  the  second  case  the  false 
ideative  content  is  furnished  directly  by  the  altered  perceptive 
relations  between  the  subject  and  the  external  world,  and  by  the 

22 


338 


PSYCH  I A TRY 


disturbed  associative  process.  The  deranged  sensory  functions 
supply  false  notions,  and  these  furnish  the  elements  for  the  con- 
stitution of  the  delirium,  which  will  be  general  or  partial,  systema- 
tized or  not,  according  as  the  hallucinations  are  multiple  and 
tumultuous,  or  single,  uniform,  and  persistent. 

As,  in  the  course  of  thought,  there  are  presented  ideas  that  are 
coloured,  active,  and  efficacious,  so  in  deliria  we  can  distinguish 
those  that  are  more  or  less  active,  those  that  run  their  course  with 
correspondingly  vivacious  affectivity,  and  those  that  are  colourless 
and  lacking  in  dynamogenetic  force. 

There  are  also  rudimentary  deliria,  which  become  concreted 
especially  with  the  concurrence  of  false  perceptions,  just  as  there 
are  in  normal  life  rudimentary  ideas  which,  in  given  circumstances, 
are  concreted  with  new  observations.  Active  deliria  with  great 
dynamogenetic  energy  are  present  in  some  cases  of  psychoneurosis, 
in  paranoia,  in  alcoholic,  epileptic,  or  hallucinatory  psychosis,  as 
well  as  in  any  other  psychopathy,  before  the  onset  of  the  consecu- 
tive and  fatal  mental  weakening  (consecutive  dementia),  in  which 
last  case  even  the  delirious  ideas  suffer  from  the  weakness  that  over- 
takes the  whole  mental  life. 

Then  there  are  separate  forms  of  deliria  that  do  not  belong  to 
one  particular  psychosis  only,  but  are  the  expression  of  a profound 
disturbance  of  the  whole  psychic  life,  whatever  be  the  clinical  form 
of  the  psychosis,  but  especially  be  it  progressive  paralysis,  paranoia, 
or  consecutive  dementia.  Among  these  deliria  we  shall  consider 
particularly — 

Metabolic  Delirium. — Here  everything,  in  the  opinion  of  the 
subject,  has  changed  the  nature  that  universal  consent  attributes 
to  it  : — ‘ the  patients  are  lords,’  ‘ the  sick  are  ministers  travestied,’ 
‘ the  asylum  is  the  royal  palace,’  ‘ the  name  that  I bear  is  not  my 
true  name,’  ‘ I was  born  indeed,  but  I came  into  the  world  at 
Fontainebleau,’  ‘ my  daughter  is  only  an  adopted  daughter,’  etc. 

Some  admit  also  a delirium  of  recognition,  or  palingnostic  delirium 
(Mendel).  The  essence  of  this  delirium  is  that  the  subject  believes 
that  he  recognises  in  everything  he  sees  for  the  first  time,  or  in  a 
position  that  is  quite  new  to  him,  an  object  or  a person  that  he  had 
known  before,  or  a position  that  he  had  occupied  before.  These 
deliria  are  met  with  in  various  psychopathic  forms  with  weakening 
of  the  intellectual  functions,  especially  of  the  memory  (see  preceding 
chapter).  A delirium  like  this,  which  is  a higher  grade  of  param- 
nesia, is  found  in  paranoia,  owing  to  false  associations  of  ideas,  and 
very  frequently  in  paral3dic  dementia  and  senile  dementia.  It  is 
very  eas}^  to  find  a paralytic  subject  with  expansive  delirium  who 
will  address  you  by  name,  and  insist,  although  he  sees  ^mu  for  the 
first  time,  that  3^11  are  his  friend  ‘ Cains,’  ‘ his  dear  friend,’  that 
you  both  met  ‘ in  such  and  such  a famiK^’  etc.  Error  as  to  locality 
is  more  frequent.  One  of  Mendel’s  alcoholic  subjects  on  first  being 


PHYSIO-PATHOLOGY  OF  IDEATION 


339 


received  into  the  establishment  said  : ‘ Everything  here  seems  to 
be  as  well  known  to  me  as  if  I had  been  here  before.’  A paranoic 
observed  : ‘ Nineteen  years  ago  I was  in  this  very  room,  with  the 
same  pictures,  the  same  furniture,  and  the  same  gentlemen.’  The 
edifice  had  been  built  hardly  six  years  before.  These  disorders  are 
better  considered  as  affections  of  the  memory. 

Delirium  is  distinguished  into  acute  or  chronic,  according  as 
it  develops  and  runs  its  course  very  rapidly  and  tumultuously,  or 
slowly,  as  we  have  mentioned  above.  In  the  first  case  the  per- 
sonality undergoes  a rapid  and  complete  transformation.  In  the 
second  the  transformation  is  much  slower,  and  sometimes  partial. 

Mental  confusion  consists  in  the  dissociation  of  ideas,  in  the 
incapacity  for  reciprocal  evocation,  and  the  difficulty,  in  the  more 
serious  cases,  of  recognising  the  objects  of  the  external  world. 
This  leads  to  a dysorientation  of  the  personality  in  time  and  space. 
The  personality  is  no  longer  sure  of  itself,  the  judgment  of  identity 
is  confused  and  uncertain,  as  if  the  subject  had  lost  the  thread  of 
his  history  by  which  he  might  transport  himself  into  the  past,  and 
the  thread  of  imagination  that  leads  to  the  future. 

With  the  dissociation  of  ideas  there  disappears  the  syntactic, 
and  sometimes  also  the  grammatical,  form  of  thought. 

Isolated  groups  of  ideas,  succeeding  one  another  without  any 
bonds  of  association,  and  wanting  any  correspondence  with  real 
things,  follow  one  upon  another,  like  the  ruins  of  an  edifice  that 
has  crumbled  away  ; but  these  ruins  give  evidence  of  the  former 
construction,  and  the  remaining  decorations  enable  us  to  recall  the 
modest  habitation  of  the  bourgeois  or  the  luxurious  mansion  of  the 
rich  man.  We  must  recognise  a long  gradation  of  confusion. 

From  the  fleeting  interruption  of  thought  and  speech  due  to  an 
obstacle  in  the  associative  paths,  or  to  interference,  or  to  difficulty 
of  evocation,  causing  the  speaker  to  lose  hold  of  his  subject  and  to 
wander  into  another  field,  to  the  more  serious  dissolution  of  the 
whole  mental  content,  there  is  a very  long  series  of  forms  or  grades 
of  mental  confusion.  In  the  lowest  grades  the  subjects,  generally 
neurasthenic,  lose  the  thread  of  their  ideas,  remain  at  a loss  for  a 
time,  and  then  sometimes  exclaim  : ‘ What  was  I saying  just  now  ?’ 
In  such  cases  the  grammatical  and  syntactical  form  of  speech  is 
maintained,  but  the  logical  form  is  not  always  strictly  preserved, 
the  nexus  between  the  inference  and  the  premises,  or  between  the 
conclusions  and  the  subject  of  discourse,  being  sometimes  awanting 
[dyslogia  and  paralogia).  In  the  more  serious  cases,  passing  through 
agrammatism  and  akataphasia,  we  arrive  at  the  greatest  confusion 
of  expression,  where  not  a word  has  either  its  regular  grammatical 
inflection  or  a nexus  with  the  preceding  or  the  following  words. 
The  disorder  of  the  cerebral  activity  is  expressed  in  rapid  and  con- 
fused language,  a veritable  flight  of  dissociated  words,  sometimes 


340 


PSYCHIATRY 


whispered,  distorted,  and  not  at  all  intelligible.  This  differs  much 
from  tumultus  sermonis. 

These  states  of  confusion  may  be  either  acute  or  chronic. 
When  acute,  they  are  determined  by  hallucinations  in  the  majority 
of  sensory  phrenoses,  of  whatever  pathogenesis — infective,  auto- 
toxic, alcoholic,  febrile,  etc. 

The  chronic  form  we  find  in  consecutive  or  secondary  dementia, 
whatever  be  its  origin  or  the  nature  of  the  malady  it  succeeds. 
Sometimes  the  consciousness  is  void  of  ideative  content  ; no  repre- 
sentation is  formed  there  or  is  recalled,  either  by  external  stimuli 
or  by  any  other  mechanism.  This  is  the  case  in  states  of  profound 
stupor,  or  in  the  so-called  amentia  of  Meynert  and  others.  Both 
the  confusion  and  the  stupor  may  be  interrupted  by  hallucinatory 
episodes,  which  are  the  momentary  and  fugitive  reproductions  of 
those  more  or  less  intense  states  of  hallucination  that  originally 
determined  them. 

Incoherence  of  speech,  which  coincides  with  incoherence  of 
thought,  corresponds  to  the  so-called  dyslogia,  which  is  divided 
into  alogia  and  ^paralogia.  Accordingly,  we  may  have  aphrasia 
and  par  aphrasia.  The  latter  is  always  connected  with  paralogia, 
whilst  aphrasia  does  not  necessarily  coincide  with  alogia,  for  there 
exists  a superstitious  or  voluntary  or  thematic  aphrasia  (generally 
found  in  paranoic  and  in  hysterical  subjects).  Paraphrasia  is  to 
be  met  with  in  all  forms  and  grades  of  mental  dissociation  (inco- 
herence), and,  as  regards  time,  both  with  great  rapidity  of 
thought  (tumultus  sermonis)  and  with  slowness  of  thought 
(hradyphrasia). 

We  distinguish  verbal  paraphrasia,  characterized  by  the  use  of 
wrong  words  introduced  into  the  discourse  without  the  speaker 
noticing  them  ; he  is  not  aware  of  the  error,  as  he  intended  to  pro- 
nounce the  right  word.  This  gives  a somewhat  ludicrous  and 
baroque  turn  to  his  speech. 

Disordered  speech,  the  passing  from  one  hundred  to  one  thou- 
sand without  going  back  to  the  proper  starting-point,  goes  also 
under  the  name  of  thematic  paraphrasia  (Arndt). 

This  inconclusive  form  of  speech,  wandering  from  the  subject- 
matter,  is  met  with  in  protracted  paranoia,  in  secondary  dementia, 
and  in  all  states  of  profound  mental  decadence. 

On  the  other  hand,  if  the  formation  of  ideas  and  of  thought  is 
disturbed  in  its  whole  extent,  so  that  it  is  only  with  difficulty  that 
a single  proper  judgment  can  be  expressed,  and  if  new  words  are 
coined  to  express  the  imperfect  and  strange  thoughts,  such  neolo- 
gisms being  but  maimed  fragments  of  regular  words,  veritable 
heaps  of  syllables,  then  we  have  paraphrasia  vesana,  an  effect  of 
profound  psychic  decadence. 

The  altered  structure  of  words  in  many  cases  gives  the  appear- 
ance of  paraphrasia,  and  it  is  such  in  form,  bnt  the  mechanism 


PHYSIO-PATHOLOGY  OF  IDEATION 


341 


coming  into  play  in  the  formation  of  true  paraphrasia  is  very 
different  from  that  in  paraphrasia  vesana. 

Both  thematic  paraphiasia  and  paraphrasia  vesana  are  accom- 
panied by  disordered  syntax.  The  power  of  inflecting  words 
regularly  and  of  ordering  them  in  series  is  injured.  Such  disturb- 
ance passes  under  the  name  of  agrammatism  or  akataphasia  (Stein- 
thal). 

Sometimes  the  subject  is  indeterminate,  and  the  pronoun  is 
replaced  by  the  proper  name. 

Here  is  an  example  of  paraphrasia  vesana,  with  asyntactism 
and  akataphasia  : 

Oh,  cittade  tutta  di  si 
bel  tuo  cielo, 

Che  Napoli  discese  a di 
signoreggiar  Regina 
Fra  le  di  tante  inumeri 
cittadi  adfini 

Ove  r ingegno  ad  arte  di  com- 
merci  industrie 
I tanti  di  tanti  donne  madri 
figli  e figlie  nacqiii 
a d’  immortalarsi  per 
sempre 

In  forza  di  quella  fede  a 
di  caritade  simbolo 
Qual  di  reggendone  sicurtade  per 
pill  di  cio  che 
ebbero 

In  di  tradizione  lettine  ed 
uditin  verbi 
Di  quelle  parole  prime 

uditin  voci  scritture  d’  avuten  libro.* 

Dysgrammatism  may  be  voluntary  or  involuntary.  It  is  volun- 
tary in  some  forms  of  paranoia,  as  when  the  patient  believes  he  has 
to  transform  the  language  and  grammar,  so  as  to  correspond  with 

* The  example  given  above  can  hardly  be  translated.  The  following 
utterances,  committed  to  paper  as  they  fell  from  the  lips  of  a patient  in 
Hawkhead  Asylum,  may  serve  in  its  stead  : 

‘ I’m  a jointer  born  child  being  ’culiarly  born  in  my  mother’s  womb 
for  to  catch  the  end  to  benefit  you  doctors.  It  stands  to  reason  a young 
child  is  unable  to  carry  the  grandmother  within  the  frame  of  the  frame. 
We’ve  all  got  condemned  criminal  cases  to  face  for  sucking  the  breath  of 
the  young  towards  our  own  breath.  My  cousin  used  to  domeer  over  I, 
and  we  were  playing  just  naturally  playhood  but  the  boy  pulled  the  heart 
because  its  a thought  poit  toit  heart  twitch.  My  enemy  sucks  through 
the  babehood’s  breath,  that  is  the  liquid  confidence  we  should  grow  on, 
that  is  the  quick  impulsitrive  towards  the  delivery  of  speech.  The  confidence 
and  nature  are  in  your  hands  ; that’s  why  you  have  so  striprous  patients, 
because  the  nature  is  so  close,  that  is  like  the  drum  button.  You’re  as  near 
as  any  blood  confidenter,  just  equal  towards  the  young  children  totting 
about.  Now  be  careful  towards  incontring  my  enemy.  I stand  towards 
this  building  as  towards  a thefter  and  poit  it  from  her.  The  talenters  are 
not  to  be  born  again.  . . .’ — J.  H.  McD. 


342 


PSYCHIATRy 


his  altered  formative  process  of  thought,  or  in  order  to  give  greater 
distinction  to  his  altered  personality.  It  is  not  unusual  for  the 
patient  to  speak  of  himself  in  the  proper  name — e.g.,  ‘ Fabrizio 
(instead  of  I)  demands  the  restoration  of  his  rights.’  Again,  the 
verb  may  always  be  put  in  the  infinitive  (regression). 

More  frequently  the  disturbance  is  involuntary,  owing  to 
advanced  mental  decadence. 

I have  mentioned  that  words  pronounced  by  others  are  some- 
times repeated  without  being  understood  in  cases  where  a destruc- 
tive focus  exists.  The  same  phenomenon  arises  in  the  mental  dis- 
order occurring  in  some  forms  of  dementia,  especially  paralytic 
dementia.  In  such  cases  words  cease  to  be  symbols  of  thought, 
and  simply  represent  sounds  or  voice  productions.  The  repetition 
of  these,  when  not  understood,  goes  by  the  name  of  echolalia,  or, 
better,  echophrasia  or  dysphrasia  imitator ia. 

More  or  less  profound  disturbance  of  thought  is  revealed  in 
many  other  forms  of  dysphrasia,  very  well  described  by  Morselli 
in  his  valuable  Manuale  di  semiotica  delle  malattie  mentali.  Here 
I shall  mention  only  verbal  automatisms,  such  as  the  inter- 
calation of  a word  or  phrase  between  every  two  or  three  words. 
‘ Naturally,’  ‘ you  understand,’  ‘ really,  now,’  are  very  frequently 
used  by  sane  persons,  but  they  always  show  the  prevalence  of 
automatism,  and  the  want  of  governing  power  over  the  form  of 
speech  and  the  choice  of  words.  A melancholic  subject  in  my 
Clinique  became  quite  oppressive  because  he  interlarded  his  speech 
with  ‘ really,  now.’  ‘ Really,  now,  you  cannot  understand,  really, 
now,  how  much  I suffer,  really  now.  . . .’  This  dysphrasic  disorder 
goes  under  the  name  of  emholophrasia.  If  the  interjection  is  an 
obscene  or  offensive  word,  as  when  the  patient  in  talking  with  the 
friend  who  has  come  to  visit  him  hisses  in  his  face  the  word  ‘ 7nerde  ’ 
or  ‘ cochon  ’ (cases  of  Cdiarcot  and  others),  or  another  word  very 
frequent  in  the  low  speech  of  certain  Southern  countries,  the  auto- 
matism is  stronger,  and  it  goes  under  the  name  of  coprolalia,  or, 
better,  coprophrasia. 


CHAPTER  V 


EMOTIONS  AND  SENTIMENTS— PHYSIO-PATHOLOGY 

So  far,  we  have  been  occupied  with  only  one  side  of  the  mind,  ex- 
tending from  perception  to  the  highest  products  of  the  intellect, 
and  we  have  purposely  refrained  even  from  mentioning  the  emotions 
when  we  spoke  of  the  sensations,  so  that  we  might  deal  with  them 
in  due  order  in  a special  chapter,  and  at  as  great  length  as  the 
nature  of  this  work  will  permit. 

Sensation  contains  in  itself  two  germs  that  develop  like  two 
branches  of  the  same  tree,  which  we  take  as  a symbol  of  the  psychic 
personality.  One  represents  the  intellect  and  its  various  degrees 
of  evolution,  the  other  the  degrees  and  forms  of  feeling  and  of 
emotion.  The  one  has  reference  to  the  external  world  and  its  rela- 
tions, translated  into  images  and  their  associations  ; the  other  to 
the  modifications  of  the  ego,  provoked  not  only  by  external  stimuli, 
but  also  by  simple  and  complex  mental  products.  The  one  under- 
goes constant  development,  and,  with  the  constant  aid  of  grafts 
from  the  external  world,  it  is  always  producing  new  branches  and 
new  fruits  ; the  other  is  ever  expanding  from  the  elementary  emo- 
tions of  pleasure  and  p'ain,  and  embraces  and  adopts  the  emotions 
and  sentiments  of  all  its  fellow-beings  scattered  over  the  face  of 
the  globe.  The  intellect  finds  its  objective  in  knowledge  of  the 
universe  ; the  sentiments  are  the  effect  of  experience  of  the  muta- 
tions of  the  ego  in  its  social  relations,  and  tend  to  the  fusion  of 
human  consciousness  in  its  aspiration  after  pleasure  and  its  struggle 
against  pain. 

Our  knowledge  of  the  emotions  would,  therefore,  not  be  complete, 
with  regard  to  the  present  state  of  science,  without  a complementary 
acquaintance  with  kinsesthesis. 

In  the  study  of  the  emotions  kinsesthesis  represents,  as  it  were, 
the  soil  in  which  they  germinate.  On  the  one  hand  it  furnishes  the 
somatic  phenomena  of  the  emotions  themselves,  and  on  the  other 
it  predisposes  to  representations,  which  are  the  other  constituent 
elements  of  emotions. 

The  kinsesthetic  sense  is  the  synthesis  of  all  the  sensations,  in 

.343 


344 


PSYCHIATRY 


which  the  organic  personality  is  summed  up.  Information  of  all 
the  organic  functions  and  of  all  the  work  done  by  the  organs  in  the 
various  organic  functions  of  life  is  transmitted  to  the  superior 
nerve-centres.  From  all  parts  of  the  organism,  even  the  least 
important  and  the  most  distant,  there  is  a continuous  flow  of 
nerve-waves,  establishing  relations  between  all  the  organs  and 
the  superior  nerve-centres.  To  these  are  united  all  the  specific 
sensations  through  which  we  experience  an  infinite  series  of  muta- 
tions due  to  immediate  contact  with  the  external  world,  the  ulti- 
mate result  of  these  being  the  progressive  comprehension  of  our 
own  organism,  which  becomes  ever  more  distinct  from  the  environ- 
ment, thanks  to  the  mnemonic  reproduction  of  all  the  physical 
qualities  of  the  medium,  and  of  the  modifications  that  the  organism 
undergoes  under  the  influence  of  the  agencies  acting  upon  it. 

The  informative  waves  from  the  organs  to  the  nerve-centres  do 
not  excite  true  states  of  consciousness,  and  therefore  do  not  give 
rise  to  sensations  in  the  strictly  physiological  sense  of  the  word, 
but  they  are  confluent  in  a chamber  of  harmonic  resonance,  the 
waves  of  which  are  represented  in  consciousness  as  the  sense  of 
our  own  proper  existence. 

This  sense,  which  goes  by  the  name  of  kineesthetic  sense,  if  not 
an  active  element  of  consciousness — if,  in  other  words,  it  is  not 
clearly  representative — nevertheless  gives  a particular  tone  to  con- 
sciousness, and  it  undergoes  constant  modifications  itself,  just  as 
consciousness  is  modified  under  the  influence  of  external  agents. 
The  kinaesthetic  consciousness  becomes  more  prominent  in  cases  of 
difficulty  of  function,  and  in  all  cases  of  conflict,  as  a result  either 
of  intensity  of  the  external  stimuli  (pain)  or  their  absence  (anaes- 
thesia, hypaesthesia,  paralysis),  or  because  of  an  intensified  general 
tone,  or  a dissonant  note  arising  from  some  organ  and  disturbing 
the  harmony  of  the  waves  in  the  chamber  of  resonance.  In  this 
case  there  is  a feeling  of  discomfort  and  of  lowering  of  tone,  and 
the  result  is  a new  attitude  of  the  consciousness.  It  is  the  kinaes- 
thetic  sense  that  regulates  the  sensibility  of  the  personality,  which 
is  one  of  the  factors  of  emotivity. 

We  must  add  that  the  variations  of  the  tone  of  the  kinaesthesis 
tend  to  recall  to  consciousness,  through  the  law  of  association, 
determined  categories  of  ideas,  aspirations,  and  tendencies,  whence 
arise  those  particular  attitudes  that  represent  the  inclinations  and 
emotive  susceptibilities  peculiar  to  separate  individuals. 

The  anatomical  field  of  the  kinaesthesis  may  be  considered  to 
be  the  greater  part  of  the  cerebral  mantle,  in  so  far  as  even  the  specific 
senses  in  their  respective  zones  possess  their  own  motor  centres,  and 
perhaps  also  tactile  representations  ; but  certainly  the  centre  of 
greatest  kin^esthetic  intensity  is  the  somaesthetic  zone,  described  in 
detail  in  the  first  part  of  this  volume,  and  this  is  perhaps  one  of  the 
starting-points  of  certain  somatic  phenomena  of  emotions,  just  as 


EMOTIONS  AND  SENTIMENTS 


345 


it  is  the  point  of  confluence  of  all  the  representations  reaching  it 
from  the  respective  areas,  according  to  the  well-kncwn  law  of  the 
jeflexes. 

There  is  no  emotion  or  sentiment  that  has  not  its  root  in  the 
kincEsthesis  ; there  is  none  that  has  not  been  prepared  in  its  great 
laboratory.  It  is  that  which  gives  the  individual  emotive  sensi- 
bility, which  participates,  probably,  in  the  mechanism  of  expression, 
which  lends  colour  and  emotive  direction  to  representations. 

In  truth,  emotions  and  sentiments  are  only  evolutionary  grades 
of  states  of  consciousness,  with  more  or  less  complicated  and  con- 
scious reflexes.  The  first  of  these  is  the  fundamental  sensation  of 
pleasure  or  pain,  which  simple  stimuli,  penetrating  the  kinsesthetic 
sense,  produce  in  contact  with  the  body.  The  higher  emotions  are 
products  of  the  sense  attached  to  the  moral  and  intellectual  field, 
and  accompanying  the  struggle  and  rush  for  existence.  This  evolu- 
tion is  due  to  the  progressive  fusion  of  new  components  that  are 
furnished  by  the  relations  of  each  individual  with  others,  so  that 
the  primitive  sensation  of  pleasure  or  pain,  from  being  individual, 
becomes  universal. 

On  the  other  hand,  pleasure  and  pain  become  more  complex 
through  the  development  of  the  nervous  system,  since  the  differ- 
entiation of  stimuli — rendered  possible  by  the  progressive  increase 
of  the  nervous  system  and  the  differentiation  of  its  parts — is  con- 
stantly furnishing  new  forms  of  pleasure  and  pain,  which  become 
fused  with  the  pleasure  or  pain  of  the  whole  organic  unit,  which  is 
itself  in  constant  evolution. 

The  fundamental  law  is  that  every  stimulus  that  operates  upon 
us  modifies  the  ego  in  the  sense  of  pleasure  or  of  pain,  according  as 
it  furnishes  elements  that  can  be  assimilated  and  are  favourable  to 
the  existence  of  the  psycho-organic  unity  or  elements  that  tend  to 
its  disintegration  and  are  hurtful  to  it.  In  general  terms,  pain  may 
be  interpreted  as  an  interference  with  the  process  of  nutrition,  and 
pleasure  as  an  elevated  power  of  nutrition  in  the  organ  (Mead, 
‘ A Theory  of  Emotions  from  the  Physiological  Standpoint,’ 
Amer.  Journ.  of  Psych.,  1893-1895).  This  corresponds  with 
the  hypothesis  of  Gilmann,  according  to  which  the  source  of 
all  pleasure  is  the  renewal,  on  the  part  of  the  nerves,  of  the  activity 
that  has  already  become  familiar  to  them,  while  pain  has  its  source 
in  the  violation  of  nervous  habitude. 

In  the  more  highly  evolved  grades,  harmony  and  good  adapta- 
tion denote  the  line  of  pleasure,  whilst  disharmony  and  faulty 
adaptation  are  the  origin  of  pain.  This  had  already  been  noted 
by  Aristotle,  Hobes,  Kant,  and  Schopenhauer.  Adaptation  is  a 
form  of  penetration  of  the  organism  into  its  environment,  and  is 
therefore  favourable  to  development. 

In  their  essence  pleasure  and  pain  are  intimately  related  with 
the  facility  or  the  difiiculty  of  the  psycho-physical  (biological)  pro- 


346 


PSYCHIATRY 


cesses,  of  whatever  grade  these  may  be.  The  pain  produced  by 
fatigue,  which  we  have  all  experienced,  and  which  has  been  specially 
treated  by  Hermann  and  Funke,  arises  from  difficulty  in  the  psychic 
and  reactionary  processes.  Fere  has  noted  the  rise  of  a secret  and 
mystic  sense  of  things  related  to  the  loss  of  muscular  power  (‘  Pes- 
simisme  et  impuissance,''  Revue  Philosoph.,  1886). 

Effective  working  of  the  psychic  functions  is  a cause  of  pleasure, 
just  as  an  obstacle  to  these  functions  is  a cause  of  pain  (Meynert 
and  Gilmann).  The  rapid  representation  of  things  is  a source  of 
pleasure,  while  retardation  of  memory  is  a cause  of  pain. 

Wherever  there  is  internal  motion  or  exteriorization  in  response 
to  the  needs  of  life,  there  is  pleasure.  An  obstacle  is  the  beginning 
of  pain.  A need,  an  inclination,  and  a tendency  always  imply  a 
motor  innervation  of  some  degree  or  other  (Ribot),  and  this  motor 
innervation  is  pleasurable  or  painful  according  as  the  movement  is 
actually  effected  or  is  hindered.  Hunger,  which  awakens  a desire, 
is  a pleasurable  sensation  if  it  can  be  satisfied,  for  many  people 
suffer  pain  fromi  want  of  appetite,  though  they  have  the  means  to 
satisfy  it  ; but  it  becomes  a painful  sensation  when  there  is  any 
obstacle  whatever  to  its  satisfaction.  The  same  physiological  con- 
dition will  appear  in  consciousness  as  painful  or  pleasurable,  accord- 
ing to  the  representation  accompanying  these  tendencies. 

The  general  character  of  all  forms  of  pain  is  that  they  are  in- 
tolerable— that  is  to  say,  they  generate  disquiet  and  rebellion  on 
the  part  of  the  body,  with  a tendency  to  flee  from  the  cause  of 
pain,  and  to  remove  everything  that  irritates  or  afflicts  us,  where 
the  nature  of  things  permits  of  this.  In  this  fact  (the  aversions  of  , 
L.  Miller)  we  recognise  the  reflex  motor  mechanism,  or,  in  other 
words,  the  reaction,  which  assumes  as  many  forms  and  grades  as 
there  are  aversions. 

According  to  some  authors,  pleasure  and  pain  are  bound  to- 
gether with  a higher  order  of  psychic  phenomena,  and  they  are  i 
interpreted  by  Wundt  and  by  Ward  as  attention  to  the  proper  ; 
object.  Every  stimulus  that  fails  to  excite  some  degree  of  atten- 
tion remains  indifferent,  and  if  attention  is  awakened,  one  of  two  ; 
things  happens  : either  attention  is  exercised  with  full  liberty, 
without  impediment,  and  then  we  have  pleasure  ; or  attention  is 
disturbed  by  the  consciousness  of  inhibition,  as,  for  example,  in  the 
case  of  fixed  ideas,  and  we  have  then  a feeling  of  pain. 

Sidney  E.  Mezes  completes  this  concept  of  Wundt,  and  defines 
the  limit  of  pleasure  as  attention  without  obstruction  or  difficulty, 
while  pain  is  attention  with  obstruction.  All  states  of  intense 
attention,  resolving  itself  into  vigorous  thought  or  efficacious 
work,  are  pleasurable,  while  all  states  of  internal  conflict,  hesitation, 
and  practical  difficult}^  with  coexisting  inefficient  impulses,  are 
painful. 

Miller  brings  up  an  ancient  theory,  according  to  which  desire 


EMOTIONS  AND  SENTIMENTS 


347 


is  a primary  fact,  and  pleasure  and  pain  are  secondary.  He  holds 
desire  to  be  the  fundamental  and  primary  fact,  inasmuch  as  it  gives 
rise  to  movements  of  attraction  or  repulsion,  in  which  lies  the  essence 
of  pleasure  and  pain.  According  to  this  theory,  the  law  of  the 
reflex  would  be  inverted,  as  if  pleasure  came  from  the  completed 
ruovement  or  from  the  tendency  to  movement,  which  may  also 
coincide  with  inefficacious  desire. 

We  might  adopt  the  hypothesis  of  Marshall,  that  pleasure  is 
experienced  when  physical  activity,  coincident  with  the  psychic 
state  that  is  connected  with  pleasure,  involves  the  use  of  an  excess 
of  accumulated  force,  the  potential  of  which,  resolved  into  actual 
energy,  exceeds  what  the  stimulus  habitually  demands  ; whilst  the 
psychic  state  connected  with  pain  arises  when  the  potential  of  the 
resolved  energy,  owing  to  the  deficient  nutrition  of  the  organs  from 
which  it  emanates,  is  inferior  to  what  the  stimulus  habitually 
demands.  Pleasure  and  pain  would  therefore  be  primary  qualities, 
psychic  states  determined  by  the  relations  between  the  activity 
and  the  capacity  of  the  organs  of  consciousness. 

Other  physiologists  and  psychologists  have  adopted  the  idea  of 
Herbert  Spencer,  that  pleasure  is  a concomitant  of  all  medium 
activity.  Wundt  also  says  that  in  every  sensory  domain  excita- 
tions of  moderate  intensity  are  accompanied  by  the  feeling  of 
pleasure,  and  this  is  confirmed  by  the  fact  already  adduced  by 
Ribot  that  excessive  pleasure,  or  pleasure  that  is  too  prolonged, 
is  very  often  transformed  into  its  contrary.  What  is  best  for  the 
nerves,  says  Richet,  is  a moderate  excitation,  bringing  all  their 
activity  into  play  without  giving  rise  to  fatigue  {Revue  Scientifique, 
1896). 

It  is  useful,  however,  to  draw  a distinction  between  what  pro- 
duces pain  and  wRat  is  simply  not  pleasure.  The  latter  condition 
may  also  refer  to  something  that  is  expected  (with  prevalence  of 
the  mnesic  phenomenon).  Further,  there  are  sensations  that  are 
not  pleasurable,  and  yet  are  not  true  pains,  such  as  the  flavour  of 
beer  and  the  painful  states  arising  from  unsatisfied  appetite,  in  so 
far  as  the  psychic  correlative — that  is,  the  experience  formed  in  a 
precedent  state,  and  carried  to  a high  degree  of  tension  by  repeated 
efforts — translates  itself  into  an  impeded  psycho -physical  function. 
On  the  other  hand,  the  facilitated  functioning  into  which  the 
appetite  is  resolved  restores  equilibrium  to,  or  levels  down,  the 
psycho -physical  tension,  and  in  that  consists  the  pleasure  of 
satisfaction. 

Several  psychologists,  among  the  most  modern  of  them  Kiilpe, 
Marshall,  Calkins,  admit  the  existence  of  experiences  of  indiffer 
ence — that  is  to  say,  experiences  without  any  emotion,  either  pleasur- 
able or  painful.  An  object  remains  always  of  one  and  the  same 
form  or  colour,  but  it  is  not  alw^ays  either  pleasurable  or  painful. 
Further,  frequently-repeated  stimuli  become  indifferent,  unless  they 


348 


PSYCHIATRY 


are  very  strong.  At  the  utmost,  we  may  speak  of  very  low  or  in-  | 
finitesimal  degrees  of  pleasure  and  pain,  giving  certain  categories  | 
of  sensations  and  representations  that  assume  the  character  of  | 
indifference,  most  often  due  to  habit  ; but,  for  my  part,  I am  of  | 
opinion  that  in  all  psychic  facts  of  perception  and  representation  | 
there  exists  an  emotional  element  that  is  pleasurable  or  painful.  | 

It  is  certain  that  all  the  theories  of  pleasure  and  pain  will 
not  fully  satisfy  the  reader,  because  the  nature  of  the  subject  has 
hitherto  prevented  any  experimental  proof;  and  as  the  pheno-  ■ 
menon  is  of  an  altogether  subjective  character,  it  is  no  wonder  ' 
that  individual  writers  have  not  considered  all  the  sides  of  this  : 
complex  phenomenon.  | 

As  regards  pain  three  hypotheses  have  been  offered.  According 
tc  the  first,  pain  is  a something  connected  with  sensation;  the 
second  makes  pain  a distinct  sensation;  and  the  third  considers 
pain  as  simply  a degree  of  sensation. 

As  we  must  consider  psychic  pain  to  be  of  the  same  nature  as 
physical  pain,  we  shall  have  to  adopt  some  theory  of  psychic  pain 
that  is  similar  to  the  theory  adopted  to  explain  physical  pain.  If 
we  cannot  show  that  it  has  a particular  and  specialized  anatomical 
basis— and  up  till  now  this  has  not  been  proved— we  must  agree  that  ! 
in  the  mental  field  pleasure  and  pain  are  to  be  considered  as  pheno-  . 
mena  determined  by  the  facility  of  the  interchange  of  components 
of  consciousness  at  the  time  of  action  ; determined,  further,  by  the 
nutritive  state  of  the  organs,  and  therefore  of  the  kinaesthesis.  i 

The  question  of  the  psychology  of  pain  is  connected  with  the 
other  question  of  the  existence  of  special  nerves  for  pain  ; in  other  i 
words,  do  there  exist  special  nerves  for  pleasure  and  pain  ? This  1 
point  has  been  passionately  debated  by  Wundt,  Holding,  Kiilpe, 
Sully,  Bradley,  Marshall,  Strong,  Hoppeneimer,  Soury,  and  many  j 
others.  Some  find  an  argument  in  favour  of  the  existence  of  special  i 
nerves  for  pain  in  the  fact  that  disease  brings  about  the  dissocia-  | 
tion  of  the  painful  phenomena  from  the  tactile  and  thermic  I 
phenomena.  j 

It  is  known  that  sensibility  to  pain  can  be  suppressed,  and  tactile  1 
sensibility  preserved.  This  is  seen  under  the  action  of  cocaine,  i 
ether,  chloroform ; in  tabes  dorsalis,  in  hysteria,  hypnotism,  etc.  | 
There  may  be  painful  sensations  of  heat  and  cold  with  the  absence  , 
of  tactile  sensibility,  or  slight  tactile  sensations  may  produce  pain, 
uhile  even  intense  thermic  stimuli  of  heat  and  cold  pass  unnoticed.  ; 
These  lacts  would  lead  us  to  conclude  for  the  existence  of  distinct  | 
foims  of  painful  sensibility  to  heat,  cold,  and  tactile  stimuli.  On  j 
the  othei  hand,  it  is  known  that  mere  intensification  of  the  degree 
of  stiinulation  to  a certain  point  becomes  painful. 

\\  undt  has  attempted  to  conciliate  the  contradictions  between 
the  facts  mentioned,  by  the  h3’pothesis  that  in  the  peripheral  nerves 
the  paths  are  the  same  for  painful  excitations  and  for  others  ; in  I 


EMOTIONS  AND  SENTIMENTS 


349 


the  medulla,  tactile  sensations  and  those  of  heat  and  cold  pass 
through  the  white  substance,  while  painful  excitations,  which  are 
a simple  modality  of  the  preceding,  resulting  from  a sum  of  stimuli, 
would  appear  to  be  propagated  through  both  the  white  and  the  gray 
matter. 

On  the  other  hand,  Nichols  has  observed  that  in  some  cases,- 
pathological  and  normal,  pain  may  be  experienced  without  the 
simultaneous  sensation  of  touch,  heat  or  cold,  so  that  if  the  pain 
corresponding  to  an  excess  of  current  were  propagated  in  the  gray 
matter,  the  other  part  of  the  current  that  must  pass  through  the 
white  columns  would  have  to  give  the  tactile  sensation,  and  that 
does  not  happen.  In  my  opinion  this  argument  also  is  very  weak, 
and  does  not  impair  the  doctrine  of  intensity  in  relation  to  pain. 
Pain  is  always  the  cr}^  of  alarm  of  the  threatened  life  of  the  nervous 
element,  and  its  propagation  through  collateral  paths  such  as  those 
passing  through  the  gray  spinal  matter,  is  due  only  to  the  increased 
tension  in  the  ordinary  paths.  The  painful  sensation,  owing  to  its 
intensity,  does  not  permit  of  the  perception  of  tactile  impressions, 
which  are  added  to  the  painful  ones,  and  masked  by  them  in 
consciousness. 

Richet  and  Landois  consider  pain  to  be  the  effect  of  the  intensity 
of  the  stimulus.  Pain  may  be  provoked  either  by  an  intense  excita- 
tion or  by  a sum  of  weak  excitations  (Richet).  As  physical  pain 
is  connected  with  the  diminution  and  disorganization  of  the  vital 
functions,  so  moral  pain  may  be  interpreted  as  the  effect  of  intense 
stimuli,  or  of  a sum  of  stimuli,  acting  upon  the  psychic  personality. 
It  is  psychic,  and  the  factors  that  produce  it  are  psychic,  with  or 
without  a state  of  psychic  hyperaesthesia.  Like  somatic  pain,  it 
has  no  special  paths  or  special  centres.  All  the  theories  that  tend 
to  localize  pleasure  and  pain,  and  the  emotions  generally,  break 
down  in  face  of  the  difficulty  of  proof. 

Mann’s  hypothesis  (‘  Klinische  u.  anatomische  Beitrdge  zur  Lehre 
von  der  spinalen  Hemiplegie,''  Deutsche  Zeitsch.  /.  N evvenheil- 
kunde,  1896),  which  excludes  the  probability  of  the  existence  of 
two  paths  in  the  spinal  medulla — one  for  painful  and  thermic  sensa- 
tions, and  the  other  for  tactile  sensations — but  admits  that  tactile 
sensations  possess  a path  of  summation  besides  the  direct  path,  and 
that  pain  is  only  a symptom  of  this  phenomenon  of  summation, 
overthrows  the  other  theory  of  Frey  (‘  Untersuchungen  iiher  die 
Sinnesfunktionen  der  menschlichen  Haul'  Gesellsch.  der  Wiss. 
Bd.  xxiii.,  1896),  who  holds  that  the  sense  of  pain  possesses  terminal 
apparatus  and  specific  nerves  analogous  to  the  other  sensory  nervous 
apparatus  and  conductors.  This  last  hypothesis  takes  no  account 
of  the  researches  of  Adam  Giaglinski,  which  have  brought  to  light 
a long  bundle  passing  across  the  gray  matter  between  the  fore-part 
of  the  posterior  columns  and  the  central  canal,  in  the  neighbour- 
hood of  the  posterior  commissural  fibres,  and  intended  probably  for 


350 


PSYCHIATRY 


the  transmission  of  painful  sensations  ; nor  does  it  make  use  of 
the  seductive  hypothesis  of  Nichols,  who  assumes  that  the  nerves 
of  pain  have  the  task  of  replying  to  excessive  stimulus,  as  a defence 
against  violent  and  offensive  influences,  the  ordinary  nerves  ceasing 
to  functionate  when  the  stimulus  is  intense.  I prefer  to  adhere 
to  my  old  opinion  (Scmiotica  delle  malattie  del  sistema  nervoso, 
1889),  which  is  held  also  by  others,  including  Soury,  who,  in  ‘ Le 
Systeme  nerveux  central'  Paris,  1899,  vigorously  defends  the  doc- 
trine which  attributes  to  pain  neither  specific  quality  of  sense, 
specific  centre,  nor  special  nerve-paths. 

It  is  known  that  tactile  sensation  becomes  sensation  of  pressure, 
and  then  painful  sensation  ; the  thermic  sensations  of  heat  and  cold 
become  painful  only  as  their  thermic  degree  is  more  or  less  increased 
(the  physiological  threshold  of  this  pain  is  well  known).  The 
higher  special  senses  may  also  furnish  painful  sensations  when  the 
specific  stimuli  exceed  a determined  limit  of  excitation.  An  intense 
light  and  a very  loud  noise  are  painful. 

Goldscheider,  who  is  here  followed  by  Luckey,  proposes  to  dis- 
tinguish three  grades  of  pain.  The  first  grade  is  represented  by 
localized  physical  pain  ; the  second  by  undefined  pains  or  painful 
sensations,  such  as  discomfort  in  the  stomach,  cephalea,  etc.  ; and 
the  third  by  psychic  pain,  which  is  found  in  a morbid  degree  in 
melancholia  and  similar  states. 

The  general  law  of  the  origin  of  pain  is  therefore  to  be  stated  as 
the  sum  of  stimuli  tending  either  to  destroy  the  nerve-element 
or  to  disintegrate  it  more  than  is  necessary  to  overcome  the  obstacle. 
This  law  adapts  itself  with  very  great  probability  to  all  forms  of  pain. 

The  evidence  of  the  physical  phenomena  accompanying  and 
giving  expression  to  emotion  cannot  be  considered  as  evidence  of 
the  seat  of  the  psychic  pain,  just  as  the  muscular  phenomena  fol- 
lowing titillation  do  not  prove  that  their  centre  is  also  that  of  the 
particular  sensation  that  excites  them. 

It  is  worthy  of  note  that  in  states  of  pleasure  and  of  pain  there 
are  always  important  modifications  of  the  circulation  and  respira- 
tion. Now,  the  fact  that  these  two  functions  have  a cortical  centre 
(see  Part  I.  of  this  work)  in  the  region  of  the  somaesthetic  zone,  and 
other  subcortical  centres,  does  not  authorize  anyone  to  consider 
that  zone  or  the  subcortical  centres  as  centres  of  the  emotions. 
At  the  utmost  they  may  be  considered  as  the  anatomical  base  of 
the  kinaesthetic  sense,  and  we  have  already  said  that  kinaesthesis  is 
a constant  component  of  all  emotions.  On  the  other  hand,  Flechsig 
thought  that  all  emotions  and  passions  accompanied  by  disturbance 
of  the  circulation  and  the  respiration  must  have  their  origin  and 
their  seat  in  the  tactile  zone  of  the  cerebral  mantle,  which,  in 
his  opinion,  is  also  the  cortical  centre  of  the  feelings  that  become 
conscious. 

Kirchhoff  also  subscribes  to  this  theory  with  slight  modifications 


EMOTIONS  AND  SENTIMENTS 


351 


(^Neucre  Ansichtcn  iiber  ortlicnen  Gnindlagan  geistigev  Stdnmgen" 
Halle,  1896).  He  limits  the  area  of  painful  sensations  still 
further,  confining  it  to  that  tract  of  the  gyrus  fornicatus  which, 
lying  on  the  internal  aspect  of  the  hemisphere,  is  included  by 
Flechsig  in  the  circumference  of  the  somaesthetic  zone.  To  this 
zone  he  considers  that  painful  sensations  are  irradiated,  especially 
through  the  corona  radiata  of  the  optic  thalamus,  which  is  the- 
centre  of  the  imitative  movements  of  pleasure  and  pain,  and  would 
appear  to  be  the  centre  at  which  the  spinal  waves  are  transformed 
into  painful  waves,  the  latter  becoming  conscious  in  the  gyrus 
fornicatus,  from  w^hich  they  are  propagated  through  the  whole 
mantle — the  organ  of  thought. 

If,  on  the  one  hand,  the  somsesthetic  zone  contains  cells  that  give 
rise  to  motor  fibres  for  the  voluntary  muscles,  as  has  been  proved 
by  numerous  experimental  and  histological  researches,  on  the  other 
hand  it  has  cells  whose  axis-cylinder  prolongations  directly  or  in- 
directly reach  the  muscles  of  respiration  and  the  circulatory  ap- 
paratus ; also  others  to  which  there  come  fibres  transmitting  the 
sensations  that  arise  from  disturbance  of  the  mechanism  of  the 
circulation  and  of  the  other  parts  and  functions  of  the  organism. 
It  is  there  that  hunger,  thirst,  and  sexual  wants  come  into  con- 
sciousness, and  it  is  in  this  sphere  that  the  disposition  of  the  mind 
is  moulded  in  the  kinsesthetic  consciousness.  This  would  justify 
the  affirmation  of  Flechsig  that  the  tactile  sphere  is  the  central 
focus  of  the  emotions  and  passions. 

According  to  Flechsig  and  Kirchhoff,  emotional  and  passional 
states  are  transmitted  from  the  tactile  zone  to  the  periphery  by 
means  of  the  optic  thalamus,  and  especially  to  the  dorso-median 
nucleus,  which  has  a great  number  of  connections  with  the  tactile 
zone.* 

* M.  Calkins  has  attempted  to  formulate  a theory  of  the  localization  of 
pleasure  and  pain.  I think  it  best  to  repeat  here  the  words  of  the  authoress 
(‘An  Introduction  to  Psychology,’  New  York,  1901):  ‘Pleasure  and  pain 
are  given  by  the  excitation  of  the  cells  of  the  frontal  lobes,  when  they  are 
reintegrated  or  fatigued.  The  excitation  is  transmitted  to  the  frontal  lobe 
by  fibres  coming  from  the  motor  cells  of  the  Rolandic  zone.  When  the 
cells  of  the  frontal  lobes  are  well  nourished  and  not  fatigued — that  is,  in  a 
state  of  anabolism— they  react  more  than  adequately  to  the  excitation  that 
is  transmitted  to  them  from  the  Rolandic  zone,  and  there  is  pleasure.  On 
the  other  hand,  when  the  cells  of  the  frontal  lobes  are  ill-nourished  and 
exhausted — that  is,  in  a state  of  katabolism — they  react  inadequately  to 
the  excitation  arriving  from  the  Rolandic  zone,  and  there  is  pain.  Lastly, 
if  the  activity  of  the  cells  of  the  frontal  lobes  corresponds  exactly  to  that  of 
the  excitation,  the  experience  will  be  neither  pleasurable  nor  painful — that 
is  to  say,  it  will  be  indifferent.” 

Kitchener  attributes  the  emotions  of  pleasure  and  yiain  not  solely  to  the 
nutritive  condition  of  the  frontal  lobe,  but  to  the  general  effects  produced 
by  any  stimulus  upon  the  whole  nervous  system. 

As  a rule  this  effect  is  translated  either  into  a j)rocess  of  reintegration 
(anabolism)  or  into  one  of  disintegration  (katabolism). 


352 


PSYCHIATRY 


But,  in  the  first  place,  what  is  emotion  ? Emotion  is  a state 
of  consciousness  concomitant  with  those  instinctive  reflex  and  co- 
ordinated phenomena  that  arise  from  the  perception  or  the  repre- 
sentation of  definite  objects,  and  that  contain  the  elements  of  in- 
tegration or  disintegration  of  the  organism,  taken  in  the  fullest 
sense  of  the  word,  both  physical  and  psychical.  The  two  pri- 
mordial forms  of  emotion  are  pleasure — which  is  connected  with  all 
that  integrates  or  increases  the  organism,  physical  and  mental — I 
and  pain — connected  with  all  that  tends  to  disintegrate  or  diminish  | 
it. 

Whilst  the  cast  of  mind  has  its  roots  in  the  kinaesthetic  sense, 
and  is  good  or  bad  according  as  all  the  parts  of  the  organism 
perform  their  function  harmoniously,  or  not,  emotion  arises  from 
some  fact  or  other  that  destroys  the  kinaesthetic  equilibrium,  and 
tends  to  diminish  or  to  increase  the  psychic  personality,  to  aid 
or  to  resist  some  of  its  tendencies  or  its  intellectual  or  affective 
components. 

Somatic  concomitants  of  pleasure  are — increase  of  the  circula- 
tion in  the  head  without  a corresponding  increase  of  the  arterial 
pressure  (according  to  Meynert,  who  admits  vascular  dilatation 
with  diminished  arterial  pressure),  volumetric  dilatation  of  the 
peripheral  organs  (Lehmann,  Die  Haupt  esetze  des  menschlichen 
Gefiihlslehens,  Leipzig,  1892),  increase  of  the  pulse,  acceleration 
of  the  heart’s  action,  radiant  visage  (or,  as  commonly  expressed, 
face  glowing  with  joy),  increased  power  of  sensation,  rapidity 
and  energy  of  movements,  increased  depth  of  inspiration,  with 
accelerated  respiratory  rhythm  and  increase  of  muscular  power. 
Pleasure  is  dynamogenetic  (Fere,  Sensation  ct  Mouvement,  Paris, 
1887). 

Somatic  concomitants  of  pain  are — diminution  of  the  diameter 
of  the  vessels,  through  contraction  of  the  vascular  walls  ; pallor  of 
the  skin,  owing  to  ischaemia  ; diminution  of  certain  secretions,  the 
mouth  becoming  dry  and  the  milk  disappearing,  and  the  increase 
of  certain  other  secretions,  such  as  tears  ; constriction  of  the  pul- 
monary vessels,  giving  rise  to  that  sense  of  oppression  noticed  by 
all  who  are  under  the  tyranny  of  pain  ; feeling  of  cold  ; want  of 
tone  in  the  voluntary  muscles,  whence  the  head  bowed  down  (‘  bent 
with  sorrow,’  as  Lange  says),  the  face  lengthened , and  the  lower 
jaw  slightly  drooping  ; weakness  of  the  voice  ; increased  size  of 

Another  theory  of  localization  is  that  of  Miinsterberg,  who  offers  the 
hypothesis  that  the  innervation  of  the  cells  and  of  the  fibres  connected  with 
the  extensor  muscles  produces  pleasure,  while  the  excitation  of  the  cells 
and  the  fibres  connected  with  the  flexor  muscles  gi’^'es  the  emotion  of  pain. 

For  my  part,  I cannot  enter  into  a long  discussion  with  regard  to  these  theories 
of  localization,  and  I cannot  agree  with  any  hypothesis  that  tends  to  localize 
the  emotions.  After  what  I have  said  about  the  functions  of  the  frontal 
lobe  in  the  first  part  of  this  work,  I must  conclude  here  that  these  theories 
are  all  more  or  less  premature. 


EMOTIONS  AND  SENTIMENTS 


353 


the  eyes,  with  wider  opening  of  the  palpebral  fissures.  Pain  is 
paralyzing. 

The  impossibility  of  separating  mental  representations  from  the 
somatic  concomitants  of  emotion  has  given  rise  to  two  opposite 
theories  about  the  nature  and  the  seat  of  the  emotions. 

According  to  one  theory,  emotion  consists  in  a psychic  pheno- 
menon determined  by  perceptions  or  by  ideas,  accompanied  by  a 
number  of  somatic  phenomena — vaso-motor,  muscular,  secretory, 
respiratory,  all  of  which  are  consecutive  and  reflex.  According  to 
the  other  theory,  emotion  is  constituted  essentially  of  vaso-motor, 
respiratory,  and  general  somatic  phenomena,  which  follow  imme- 
diately upon  perception  or  representation,  so  that  the  change  in 
all  these  functions,  transmitted  to  consciousness,  gives  rise  to 
emotion.  In  this  view  emotion  is  only  the  consciousness  of  mus- 
cular and  neuro  - vascular  variations.  The  names  of  James, 
Lange,  Sergi,  Pitres  and  Regis,  Soury,  Kiilpe,  Mercier,  Calkins, 
Irons,  Baldwin,  Dewey,  and  many  others,  are  connected  with  this 
disputed  question. 

Here  is  what  J ames  says  : ‘ Our  natural  way  of  thinking  about 
these  coarser  emotions  is  that  the  mental  perception  of  some  fact 
excites  the  mental  affection  called  the  emotion,  and  that  this  latter 
state  of  mind  gives  rise  to  the  bodily  expression.  My  theory,  on 
the  contrary,  is  that  the  bodily  changes  follow  directly  the  j)erception 
of  the  exciting  fact,  and  that  our  feeling  of  the  same  changes  as  they 
occur  is  the  emotion.  Common-sense  says  : we  lose  our  fortune,  are 
sorry  and  weep  ; we  meet  a bear,  are  frightened  and  run  ; we  are 
insulted  by  a rival,  are  angry  and  strike.  The  hypothesis  here  to 
be  defended  says  that  this  order  of  sequence  is  incorrect,  that  the 
one  mental  state  is  not  immediately  induced  by  the  other,  that  the 
bodily  manifestations  must  first  be  interposed  between,  and  that 
the  more  rational  statement  is  that  we  feel  sorry  because  we  cry, 
angry  because  we  strike,  afraid  because  we  tremble,  and  not  that 
we  cry,  strike,  or  tremble  because  we  are  sorry,  angry,  or  fearful, 
as  the  case  may  be.  Without  the  bodily  states  following  on  the 
perception,  the  latter  would  be  purely  cognitive  in  form,  pale, 
colourless,  destitute  of  emotional  warmth.  We  might  then  see  the 
bear  and  judge  it  best  to  run,  receive  the  insult  and  deem  it  right 
to  strike,  but  we  should  not  actually  feel  afraid  or  angry.’ 

Further  on  he  continues  : ‘ If  we  fancy  some  strong  emotion, 
and  then  try  to  abstract  from  our  consciousness  of  it  all  the  feelings 
of  its  bodily  symptoms,  we  find  we  have  nothing  left  behind,  no 
mind  stuff  ” out  of  which  the  emotion  can  be  constituted,  and 
that  a cold  and  neutral  state  of  intellectual  perception  is  all  that 
lemains.  ...  I cannot  help  thinking  that  fill  who  rightly  appre- 
hend this  problem  will  agree  with  the  proposition  above  laid  down. 
What  kind  of  emotion  of  fear  would  be  left  if  the  feeling  neither 
of  quickened  heart-beats  nor  of  shallow  breathing,  neither  of 

23 


354 


PSYCHIATRY 


trembling  lips  nor  of  weakened  limbs,  neither  of  goose-flesh  nor  of 
visceral  stirrings,  were  present,  it  is  quite  impossible  for  me  to  think. 
Can  one  fancy  the  state  of  rage  and  picture  no  ebullition  in  the 
chest,  no  flushing  of  the  face,  no  dilatation  of  the  nostrils,  no  clench- 
ing of  the  teeth,  no  impulse  to  vigorous  action,  but  in  their  stead 
limp  muscles,  calm  breathing,  and  a placid  face  ?’ 

Irons,  Baldwin,  and  Dewey  have  ranged  themselves  against  the 
theory  of  James-Lange.  The  dispute  has  been  animated  and  sup- 
ported by  a number  of  arguments  pro  and  con,  but  these  have 
rather  displayed  the  polemic  power  of  James  than  made  clear  the 
value  of  the  two  theories. 

Within  the  restricted  limits  of  this  work  it  is  impossible  for  us 
to  enter  into  the  details  of  the  discussion,  and  much  experimental 
research  will  still  be  required  before  we  can  decisively  accept  either 
one  or  other  of  the  theories.  If  once  we  could  demonstrate  that 
vaso-motor  phenomena,  like  those  that  form  the  chief  character- 
istic of  emotion,  exist  apart  from  that  particular  psychic  state 
which  is  for  some  the  specific  fact  of  the  emotions  of  pleasure  and 
pain,  whatever  be  their  forms,  the  vaso-motor  theory  of  emotion 
would  disappear  definitively  and  irreparably.  When  we  consider 
the  state  of  mind  in  a number  of  vaso-motor  disturbances  of  longer 
or  shorter  duration,  finding  there  nothing,  or  almost  nothing,  in 
the  nature  of  true  emotional  states,  we  feel  great  distrust  of  the 
somatic  theory.  In  hysteria  we  frequently  observe  cutaneous 
ischaemia,  palpitation  of  the  heart,  and  respiratory  anxiety,  while 
the  subject  is  utterly  indifferent.  In  Basedow’s  disease  we  find  a 
great  increase  of  the  cutaneous  circulation,  redness  of  the  skin, 
clear  and  sparkling  eyes,  and,  instead  of  joy  or  anger,  a sense  of 
anguish  and  of  fear  accompanies  those  somatic  phenomena. 
Hysterical  women  with  anaesthetic  skins,  ischaemia,  and  paralysis 
of  a great  number  of  their  muscles,  are  very  far  from  showing  signs 
of  sadness.  Men  afflicted  with  polyneuritis,  with  complete  paralysis 
and  muscular  flaccidity,  sometimes  with  disappearance  of  all  the 
muscular  masses,  are  for  whole  days  in  excellent  humour,  if  only 
they  are  allowed  to  hope  for  recovery.  In  the  midst  of  so  many 
contradictions,  the  mind  remains  perplexed  and  resists  the  seduc- 
tion of  the  organic  theory,  even  when  the  experimental  habit 
inclines  one  to  favour  the  doctrine  that  is  based  upon  objective 
and  demonstrable  facts. 

It  is  certain  that  between  the  first  psychic  fact  and  the  last 
fact  of  emotion  there  exist  links  that  follow  one  upon  another  in 
consciousness,  in  the  form  of  rapid  reasonings  and  fantastic  repre- 
sentations, in  which  the  end  always  is  that  the  ego  appears  to  be 
compromised  or  is  exalted.  This  fact  has  been  noticed  by  James, 
who  did  not  say,  ‘ We  are  terrified  because  we  flee  or  because  we 
tremble,’  as  the  critics  have  made  him  and  Lange  say.  What  he 
said  was  simply,  ‘ We  see  an  object,  we  tremble  and  are  terrified.’ 


EMOTIONS  AND  SENTIMENTS 


355 


Evidently  James  makes  a number  of  psychic  components  or  re- 
presentations enter  into  the  vision  of  the  object,  and  these  end  in 
compromise  or  exaltation  of  the  personality  ; but  the  trembling  is 
placed  before  the  terror,  which  proves  how  he  holds  the  genesis  of 
the  terror  to  be  due  to  the  resonance  of  the  trembling  in  a con- 
sciousness filled  with  the  image  of  the  object. 

In  my  opinion  the  weak  point  of  this  doctrine  lies  in  the  fact  ' 
that  it  is  sought  to  attribute  to  the  somatic  phenomenon  a high 
significance  in  the  origin  of  the  emotion,  whilst  in  the  conscious- 
ness that  is  perturbed  there  always  coexist  two  facts — the  repre- 
sentation, along  with  the  internal  participation  of  the  ego  itself, 
and  the  somatic  fact.  Now,  no  one  can  think  that  the  somatic  is 
the  more  important  of  the  two  components  co-existing  in  conscious- 
ness, because,  while  we  may  not  infrequently  observe,  where  no 
emotion  exists,  somatic  disturbances  analogous  to  those  noticed  in 
emotion,  we  have  no  example  of  a psychic  fact  compromising  or 
exalting  the  ego  without  being  accompanied  by  emotion  either  of 
pleasure  or  of  pain. 

Dewey  has  advanced  a theory  inclining  to  that  of  James,  but 
essentially  Darwinistic.  According  to  that  writer,  the  expressions 
of  emotion  are  in  reality  the  reduction  of  movements,  primarily 
useful,  to  habits.  These  are  only  survivals  or  modifications  of 
teleological  co-ordinations.  Here  we  meet  with  a conflict  between 
instinctive  movements  and  new  movements  determined  by  ideas, 
and  from  this  conflict  arises  a sensation  of  tension,  which  is  the 
basis  of  emotion.  If  there  is  no  conflict,  there  is  no  emotion. 

Stratton  calls  attention  to  the  point  that  if,  when  under  emotion, 
we  direct  our  attention  to  the  organic  sensations  accompanying  the 
emotion,  the  latter  ceases,  although  the  sensations  continue. 

Ferrero  introduces  the  vital  tone  of  an  individual  into  the  con- 
ception of  emotion.  He  deduces  this  from  the  fact  that  a normal 
man  in  perfect  health  is  not  troubled  at  the  thought  of  death. 
Owing  to  the  uncertainty  of  the  period  of  its  happening,  there  is 
no  feeling  of  dread,  and  for  this  reason  sailors  and  miners,  who 
are  constantly  risking  their  lives,  have  no  fear  of  death,  while 
old  and  weak  persons  think  of  it  and  fear  it  because  the  organic 
sensation  of  the  weakness  of  their  bodies  is  in  harmony  with  the 
idea  of  death. 

All  these  are  but  secondary  aspects  under  which  we  may  examine 
the  biological  problem  of  emotion,  and  it  will  easily  be  understood 
how,  in  the  light  thrown  upon  it  from  this  manner  of  examination, 
the  doctrine  of  James-Lange  appears  in  all  its  importance  to  be 
inverting  the  whole  problem  of  the  essence  and  origin  of  the  emo- 
tions. 

The  favourable  acceptance  of  such  a hypothesis  is  due  to  the 
fact  that  we  cannot  demonstrate  a subjective  state  of  emotion  dis- 
sociated from  the  somatic  phenomena,  whilst  only  these  latter 

23—2 


356 


PSYCHIATRY 


phenomena  can  be  put  to  experimental  proof,  and  the  modern 
scientific  spirit  attributes  value  only  to  such  facts  as  it  can  control, 
estimate,  and  measure  objectively.  I cannot  get  away  from  the 
conviction  that  the  psychic  components  of  emotion  are  quite  as 
important.  Among  these  the  greatest  attention  is  due  to  surprise, 
in  a large  number  of  emotions.  If  a soldier  on  the  march  comes  in 
sight  of  the  enemy,  and  is  assailed  by  fear  of  death,  and  of  the  pain 
of  rapidly  imagined  wounds,  or  if  a girl  is  terrified  on  seeing  a snake 
close  to  her  feet  as  she  walks  along  a country  path,  the  fear  and  the 
terror  in  these  cases  are  the  effects  of  the  surprise,  which  interrupts 
the  normal  course  of  the  representations  and  the  feelings,  substi- 
tuting for  them  in  consciousness  others  that  have  a disintegrating 
power.  It  is  the  imminent  threat  against  the  integrity  of  one’s 
own  physical  and  psychic  personality  that  determines  that  complex 
psycho-physical  state  which  we  call  fear. 

If  the  girl  sees  the  serpent  from  afar,  and  is  not  threatened,  or 
if  the  soldier  has  already  seen  the  enemy  several  times,  so  that  there 
is  no  surprise,  and  the  danger  appears  less  imminent,  or  even  should 
it  be  imminent,  if  the  consciousness  has  previously  been  occupied 
by  those  images  and  by  the  dangers  to  which  the  personality  has 
been  habituated  for  some  time  ; if  there  is  adaptation  of  the  con- 
sciousness to  the  new  order  of  images — as  happens  in  the  case  of 
miners  and  sailors — fear  is  absent,  and  emotion  does  not  enter  into 
the  habitual  state  of  the  mind  and  into  the  renewed  direction  of 
the  consciousness.  This  appears  to  me  to  prove  that  the  organic 
reflexes,  respiratory,  muscular,  and  vaso-motor,  do  not  follow 
immediately  on  the  representation  or  the  perception,  and  that  fear 
does  not  arise  from  those  organic  modifications,  but  is  the  effect 
of  surprise,  which  for  the  moment  disintegrates  or  threatens  the 
psychic  personality,  and  it  is  this  new  state  that  is  reflected  in  all 
the  organic  functions.  Between  perception  or  representation  and 
the  organic  phenomena  of  emotion  there  exists  a complex  psychic 
factor,  which  in  its  essence  can  be  reduced  to  the  threat  of  dis- 
integration, to  interdiction,  or  to  the  instantaneous  exaltation  of 
the  personality. 

If  a man  striving  for  a fortune  acquires  it  gradually,  he  will  not 
have  any  emotion  of  joy.  His  consciousness  gradually  integrates 
itself  with  the  image  of  the  million,  and  his  internal  satisfaction 
becomes  a feature,  a permanent  attribute,  of  the  progressive  adapta- 
tion of  his  personality  to  the  new  conditions  of  existence.  Such 
internal  satisfaction  is  not  an  emotion,  it  is  a state. 

If,  on  the  other  hand,  even  a modest  fortune  should  come  to 
him  suddenly,  as,  for  example,  the  winning  of  a prize  in  a lottery, 
his  joy  would  be  so  intense  that  he  would  run  the  risk  of  a congestive 
attack  or  of  cerebral  apoplexy.  In  this  case  it  is  the  surprise  that 
breaks  up  the  habit  of  the  consciousness  and  determines  the  emotion. 
Two  factors — the  person  and  the  fortune — are  the  same  ; the  third 


EMOTIONS  AND  SENTIMENTS 


357 


— the  duration  or  the  repetition  of  the  representation  that  creates 
the  habit  of  consciousness — is  variable.  I can  picture  this  phe- 
nomenon to  myself  in  many  cases  as  the  reversing,  at  full  speed, 
of  the  whole  machinery  of  the  cerebral  waves,  after  they  have 
acquired  motion  in  a certain  direction.  I think  it  is  very  necessary 
that  the  dvnamic  exponent  should  be  introduced  into  any  plausible 
theory  of  emotion.  I believe  that  high  nervous  tension,  produced 
by  the  surprise  that  interrupts  the  normal  course  of  thought,  while 
it  interdicts  the  higher  centres  (reasoning  and  attention),  discharges 
itself  upon  the  lower  organic  centres,  and  determines  the  reflex 
organic  phenomena  of  emotion.  Let  us  eliminate  surprise,  give 
free  course  to  thought,  and  direct  our  attention  to  the  sensation 
that  has  produced  the  emotion,  and,  as  Stratton  has  observed,  the 
emotion  ceases.  In  other  cases,  as  in  the  emotion  of  the  orator, 
which  is  prepared,  or  that  of  the  traveller  who  passes  along  deserted 
ways  by  night,  the  compromised  ego,  in  conflict  with  the  feelings 
and  impulses  that  determine  him  to  speak  or  to  travel,  places 
itself  voluntarily  in  the  circumstances  occasioning  the  emotion. 
If  the  orator  were  sure  of  himself,  and  of  the  opinion  that  others 
would  express  about  him,  and  if  he  did  not  contemplate  the  possi- 
bility of  compromising  some  of  the  components  of  his  personality, 
his  self-esteem  or  his  vanity,  then  he  would  not  be  perturbed,  just 
as  the  traveller  would  not  be  perturbed  if  he  did  not  know  that  he 
was  exposed  to  danger.  In  this  case  the  pain  or  fear  arises  from 
the  contrast  between  the  tendency  of  the  ego  to  affirm  itself  and 
the  danger  of  an  opposite  result,  which  would  mean  the  disintegra- 
tion or  the  diminution  of  the  personality. 

In  ereutophobia,  or  the  fear  of  blushing,  the  principal  and  pre- 
ponderating element  is  the  idea  of  blushing.  It  is  this  that  deter- 
mines and  provokes  the  emotion  (Pitres  and  Regis).  It  is  clear 
that  such  an  emotional  state  cannot  be  related  solely  to  the  changes 
in  the  physiognomy,  in  the  circulation,  and  in  the  muscular  tone, 
any  more  than  it  can  be  solely  related  to  the  totality  of  the  psychic 
representations  that  provoke  it.  The  fact  is  that  phenomena  of 
vascular  constriction  or  vascular  dilatation  are  observed  in  many 
weak  individuals,  especially  girls,  without,  however,  their  noticing 
all  those  modihcations  that  the  emotion  brings  into  consciousness. 
The  young  person  who  suffers  from  ereutophobia  has  been  for  some 
time  subject  to  reddening  of  the  face  and  rush  of  blood  to  the 
head,  but  she  has  no  fear  of  blushing.  This  begins  on  some  occa- 
sion when  the  subject  sees  herself,  and  imagines  that  others  are 
noticing  the  blush,  and  indulging  in  suspicions  as  to  the  cause 
of  it. 

A further  proof  of  the  weakness  of  the  somatic  theory  of  the 
emotions  is  afforded  by  those  who  suffer  from  hemiplegia  due  to  a 
lesion  so  situated  that  it  withdraws  the  thalamus  opticus  from  the 
inhibiting  influence  of  certain  parts  of  the  cerebral  mantle.  In 


358 


PSYCHIATRY 


such,  cases,  as  also  in  cases  of  extensive  cortical  lesions,  the  sufferers 
display  great  emotivity.  They  weep,  laugh,  cry  out  on  receiving 
the  slightest  impression  ; yet  it  is  evident  that  there  is  no  true 
emotion,  only  the  semblance  of  it.  The  weeping  and  the  laughter 
of  these  sufferers  are  only  simulacra  of  the  real  emotions,  and  if 
there  is  any  emotional  resonance  of  these  in  the  consciousness,  it 
is  to  be  attributed  to  old  and  repeated  associations  between  these 
somatic  phenomena  and  the  respective  emotive  states. 

In  the  ordinary  chorea  of  Sydenham,  and  also  in  other  serious 
forms  of  the  malady,  when  the  muscles  of  the  face  are  involved  in 
the  anarchy  of  the  muscles  of  the  trunk  and  limbs,  the  physiognomy 
assumes  the  strangest  expressions  of  hate,  anger,  menace,  pain,  or 
joy,  while  the  mind  gives  no  evidence,  through  corresponding  com- 
motion, of  sharing  in  the  emotion  expressed  by  the  physiognomy. 
I add  no  further  examples,  for  I believe  that  these  are  sufficient  to 
lead  to  the  conviction  that,  until  it  is  demonstrated  that  the  expres- 
sion of  the  physiognomy,  the  vaso-motor  changes,  and  the  altera- 
tions in  the  secretions  and  the  respiration  are  indissolubly  bound 
up  with  determinate  motions  or  attitudes  of  mind,  and  until  we 
can  prove  that  one  and  the  same  emotional  state  of  mind  corre- 
sponds with  one  attitude  and  one  vascular  condition,  it  is  impos- 
sible for  us  to  recognise  in  the  somatic  theory  of  the  emotions  that 
objective  quality  of  demonstration  which  supports  a theory  and 
secures  for  it  the  victory  over  others. 

It  has  not  escaped  the  notice  of  Lange  that  abundant  secretion 
of  tears,  red  and  swollen  face,  reddened  eyes,  increased  secretion 
of  the  nasal  mucus — all  symptoms  denoting  great  dilatation  of  the 
vessels  of  the  skin  and  mucous  membranes  about  the  face — coincide 
with  pain ; but,  in  support  of  his  theory,  he  supposes  that  these 
phenomena  are  consecutive,  of  the  nature  of  a reaction  against  the 
primary  constriction — a relaxation  of  the  muscles  of  the  small 
arteries  after  strong  constriction.  He  leaves  unproved,  however, 
the  very  fact  asserted — that  pain  and  anguish  are  always  accom- 
panied by  vascular  constriction,  even  if  it  be  of  short  duration. 

Now,  if  that  is  contrary  to  what  is  commonly  observed,  if  there 
exists  a number  of  states  of  pain  and  fear  that  are  accompanied 
from  their  beginning  by  vascular  dilatation  of  the  skin,  if,  indeed, 
the  sentence  of  Descartes  quoted  by  Lange  himself  be  true,  ‘ Lac- 
rimae  non  promanent  ab  extrema  tristitia,  sed  solum  a mediocri,’ 
what  would  be  left  of  the  theory  of  J ames-Lange  to  render  it  more 
positive  than  the  others  ? 

For  a long  time  we  have  been  acquainted  with  the  researches 
of  Claude  Bernard  into  the  influence  of  pain  on  the  heart  and  cir- 
culation. This  is  explained  by  the  direct  action  of  painful  stimuli 
on  the  bulb.  Frogs  from  which  all  the  brain  above  the  bulb  has 
been  removed,  so  that  they  cannot  feel  pain,  which  is  a phenomenon 
of  consciousness,  nevertheless  show  the  organic  symptoms  of  pain 


EMOTIONS  AND  SENTIMENTS 


359 


— lowering  of  arterial  pressure,  and  even  stoppage  of  the  heart’s 
action — on  compression  of  the  sciatic  nerve  (C.  Bernard,  Richet, 
F.  Frank).  The  somatic  phenomena  are  therefore  separable  from 
the  conscious  phenomenon  of  emotion  in  so  far  as  they  may  exist 
apart  from  the  conscious  fact  of  emotion,  and  therefore  it  may  be 
admitted  that  it  is  not  the  somaesthetic  zone  that  is  the  centre  of 
their  origin,  but  the  medulla  oblongata. 

The  truth  is  that  there  does  not  exist  any  strict  connection 
between  a form  of  emotion  and  a complexus  of  somatic  pheno- 
mena. 

The  few  experiments  hitherto  made  upon  the  organic  effects  of 
agreeable  and  disagreeable  stimuli  by  Anngell  and  Simon  F.  Lennan 
(‘  The  Organic  Ehects  of  Agreeable  and  Disagreeable  Stimuli,’ 
Psychological  Review,  New  York,  1896),  and  by  Binet  and  Courtier, 
do  not  strengthen  the  theory  of  James-Lange.  If  it  is  true  that 
disagreeable  stimuli  produce  a powering  of  the  level  of  the  tracing 
in  go  per  cent,  of  cases,  the  saihe  proportion  in  the  other  direction 
does  not  follow  upon  agreeable  stimuli,  for  in  many  cases  there  is  a 
lowering  extending  for  several  seconds  when  these  begin  to  act. 

Mantegazza,  who  undeniably  is  a keen  observer,  remarks  in  the 
‘ Physiology  of  Pleasure  and  Pain  ’ that  strong  painful  stimuli 
sometimes  reduce  the  heart’s  action  and  sometimes  increase  it, 
whilst  the  respiration  is  at  times  more  frequent  and  shallow,  at 
others  slower  and  deeper.  This  statement  holds  good  in  the  case 
of  the  movements  that  an  animal  makes  under  certain  conditions 
that  are  painful — as  in  flight,  for  example.  It  is  also  true  that  these 
movements  are,  as  it  were,  spasmodic,  in  one  sole  direction,  and 
debilitating,  as  has  been  observed  by  Ribot  (Psychologic  des 
Sentiments,  1890),  and  that  in  its  ultimate  analysis  pain  is  accom- 
panied by  diminution  of  muscular  energy.  Yet  it  is  indisputable 
that  the  conscious  fact  of  pain  or  of  fear  sometimes  coincides  with 
phenomena  of  an  opposite  nature  to  those  upon  which  it  has  been 
said  to  depend. 

The  assertion  of  Miinsterberg  that  agreeable  stimuli  produce 
movements  of  extension  and  disagreeable  stimuli  movements  of 
flexion  has  been  only  partly  confirmed  by  the  experiments  of  Dear- 
bon  and  Spindler  (‘  Involuntary  Motor  Reaction  to  Pleasant  and 
Unpleasant  Stimuli,’  Psychological  Review,  1897).  These  authors 
have  found  that  the  reaction  varies  according  to  the  nature  of  the 
individuals  and  their  temperaments,  some  making  many  move- 
ments of  extension  and  others  many  flexions,  whether  the  stimulus 
be  pleasant  or  unpleasant.  Under  the  influence  of  painful  stimuli 
the  flexions  are  66*6  per  cent.,  and  the  extensions  33*3  per  cent. 
On  the  other  hand,  under  agreeable  stimuli  the  extensions  are 
67-8  per  cent.,  and  the  flexions  32-2  per  cent. 

We  may  compare  the  somatic  phenomena  of  emotion  to  the 
language  through  which  thought  is  expressed.  Language  is  the 


s6o 


PSYCHIATRY 


physical  component  of  thought,  just  as  the  somatic  phenomena 
described  are  the  physical  components  of  emotion.  If  an  individual 
who  suffers  from  aphasia  due  to  a lesion  of  Broca’s  centre,  or  of  the 
first  temporal  convolution,  does  not  express  or  formulate  thoughts 
because  he  lacks  the  physical  component  indispensable  to  their 
formation  and  extrinsication,  no  one  will  think  that  thought  is 
language,  and  that  the  anatomical  base  of  language  is  the  same  as 
that  of  thought.  If  we  adopt  the  formula  preferred  by  the  up- 
holders of  the  somatic  theory  of  emotion,  we  shall  have  to  sa}’  : 
‘ I see  such  a thing  ; I name  it,  therefore  I perceive  it.’  ‘ I 
represent  to  myself  certain  images  ; these  are  reflected  on  the 
centres  of  speech,  which  furnishes  me  with  the  notion  of  things.’  I 
believe  that  such  reasoning  as  this  will  not  be  adopted  b}^  any 
psychologist. 

In  some  cases — for  example,  degenerates — emotions  of  joy  are 
expressed  by  mimicry  of  weeping.  A lady  mentioned  by  Sikorsky 
used  to  smile  in  such  a way  that  it  was  always  uncertain  whether 
she  were  laughing  or  weeping.  She  had  no  other  power  of  mimicr\v 
In  progressive  paralysis  (Schule)  and  in  hallucinatory  paranoia 
(Sikorsky)  we  often  find  the  so-called  indifferent  mimicry  in  various 
states  of  emotion. 

After  this  long  discussion  it  seems  to  me  superfluous  to  devote 
many  words  to  the  theory  of  Sergi,  which  does  not  substantially 
differ  from  that  of  James-Lange. 

Lange  distinguishes  the  group  of  emotions  from  the  group  of 
passions  and  feelings.  It  is  impossible  to  agree  with  this  distinc- 
tion of  Lange’s  in  so  far  as  regards  the  actual  essence  of  the  two 
groups  that  he  has  separated,  especially  if  it  be  remembered  that 
he  has  been  led  to  make  this  distinction  by  the  necessity  of  main- 
taining his  theory  of  emotion.  He  says  : ‘ It  is  incontestable  that 
sadness,  joy,  fear,  anger,  and  other  similar  states,  constitute  a group 
of  phenomena  distinct  from  love,  hatred,  contempt,  and  admira- 
tion, and  it  is  necessary  to  separate  them  from  the  point  of  view 
of  psychology.  It  is  only  to  the  first  group  that  I apply  the  term 
emotion  ; the  other  states  are  passions,  feelings,  or  whatever  one 
chooses  to  call  them.  ...  As  a matter  of  fact,  it  is  absolutely 
necessary  for  anyone  who  takes  up  the  physiology  of  these  pheno- 
mena to  distinguish  them  as  far  as  possible.  We  cannot  assimilate 
things  so  different  as  terror,  fury,  joy,  envy,  love,  and  the  passion 
for  liberty.  The  difference  between  these  two  groups  does  not 
consist  solely  in  the  greater  complexity  of  the  last-named  states, 
which  are  composed  of  psychic  elements  so  heterogeneous  that 
even  reflection  has  a share  in  their  formation,  but  also  in  the  com- 
plexity and  heterogeneity  of  their  efficient  conditions  ’ (Lange, 
Lcs  Emotions,  Etude  Psycho-pkysiologique,  translated  by  Dumas). 

That  is  exactly  what  has  to  be  proved.  On  the  one  hand,  every- 
thing induces  us  to  believe  that  the  second  states  represent  only  an 


EMOTIONS  AND  SENTIMENTS 


advanced  degree  of  the  first.  The  greater  advance  in  evolution 
means  that  new  components  have  been  united  to,  and  assimilated 
with,  the  first,  but  that  does  not  change  their  proper  nature  or  their 
origin.  The  same  thing  happens  with  emotion  as  with  ideas.  If, 
from  the  simple  images  of  herbs,  fruits,  and  flesh  with  which  we 
satisfy  the  sense  of  hunger  and  sustain  ourselves,  we  have  come 
to  form  the  concept  of  food  in  association  with  that  of  preserva- 
tion— perhaps  it  may  be  through  the  intervention  of  reflection, 
although  this  is  very  doubtful — that  does  not  establish  essential 
differences  between  separate  foods  and  food  in  general. 

So  also  the  brute  satisfaction  of  hunger  and  of  the  sexual  appe- 
tite is  gradually  transformed  into  the  sentiment  of  the  duty  of 
working,  into  which  there  enter  as  components  all  the  pleasures 
that  arise  from  difficulties  overcome,  and  from  the  successful 
extrinsication  of  our  increasing  activity,  as  well  as  all  those  that 
come  from  the  labour  of  others  and  from  the  beneficent  current  of 
solidarity  that  smooths  away  so  many  troubles  in  life,  and  brings 
so  much  comfort. 

These  new  components,  through  which  the  primitive  movements 
for  securing  food  have  been  transformed  into  others  much  more 
complex,  co-ordinated,  and  varied,  do  not  transform  the  proper 
emotional  nature  of  these  states.  More  complex  representations, 
new  desires,  new  motor  tendencies,  and  new  aspirations,  are  always 
at  the  bottom  of  our  struggle  for  pleasure  and  our  struggle 
against  pain.  On  the  other  hand,  with  the  suppression  of  many 
of  the  old  motor  tendencies,  the  appetite,  and  the  mode  of  satis- 
fying it,  have  been  complicated,  but  not  changed  in  nature.  Thus, 
through  continuous  grafting  of  emotional  and  intellectual  com- 
ponents, the  old  feeling  of  hunger,  that  formerly  excited  simple 
reflexes,  has  given  place  to  the  elevated  sentiment  of  the  duty  of 
labour,  which  in  its  turn  generates  reflexes  of  extreme  complication 
in  its  endeavour  to  secure  greater  comfort  in  life. 

In  this  progressive  formation  of  emotional  syntheses  we  always 
find  an  increasing  loss  of  organic  concomitants  of  the  primitive 
emotion,  and  successive  assimilation  of  the  emotions  of  the  social 
environment,  also  of  intellectual  components. 

The  evolution  of  feeling  can  take  place  only  through  the  grafting 
on  to  the  fundamental  feeling  of  the  body,  or  kinaesthetic  sense,  of 
all  the  emotional  qualities  of  the  sensations  that  give  us  our  notions. 
It  is  always  the  fundamental  feeling  of  the  organic  ego  that  is 
modified  agreeably  or  disagreeably,  and  is  incremented  by  all  the 
affective  qualities  of  the  sensations,  giving  rise,  to  two  other  sides 
of  the  ego,  the  spiritual  and  the  social  (James). 

Sentiments,  therefore,  like  ideas,  are  evolved,  and  every  stage 
of  intellect  is  a stage  of  sentiment. 

On  the  other  hand,  a group  of  intellectual  representations 
always  coincides  with  the  sentiment,  so  that  emotional  states 


362 


PSYCHIATRY 


come  to  be  associated  in  varying  proportion  with  ideative  elements 
in  consciousness. 

If  we  agree  upon  the  fact  that  all  notions  have  an  emotional 
exponent,  and  all  states  of  emotion  are  associated  with  ideative 
representations,  we  shall  understand  how,  in  proportion  as  the 
ideas  are  increased  and  thought  evolved,  the  affective  complexity 
progresses,  the  two  series  of  products  accumulating  and  constituting 
the  intellectual  and  emotional  patrimony  of  the  personality. 

In  the  sentiment  of  love  we  have  an  instance  of  those  sentiments 
that  show  a gradual  process  of  evolution,  so  that  from  being  simple 
they  have  become  complex.  The  feeling  of  love  had  its  first  be- 
ginnings in  the  simple  emotion  of  touch,  and  it  has  advanced  by 
assimilating  to  itself  a number  of  psychic  components  that  include 
even  the  highest  expressions  of  idealism.  In  a fully-evolved  man 
it  is  represented  not  only  by  tactile  and  kinsesthetic  commotion, 
but  also  by  an  aural  element,  the  voice  and  speech,  and  by  a visual 
cesthetic  element,  resulting  from  harmony  of  form.  It  is  compli- 
cated by  the  pleasure  of  possession,  of  strength,  of  generosity  in 
protection,  of  reciprocal  comfort,  of  vanity,  all  of  which  senti- 
ments are  fused  in  that  complex  which  we  call  by  the  abstract 
name  of  love. 

The  religious  sentiment  is  also  at  first  simply  a complication  of 
the  fundamental  sentiment  in  a synthesis  of  pleasures  and  pains, 
proximate  and  remote,  with  which  are  associated  intellectual  com- 
ponents— images,  judgments,  and  beliefs.  Through  it  the  indi- 
vidual who  believes  in  a Supreme  Being  denies  himself  present 
pleasures,  either  in  the  hope  of  attaining  future  pleasure  or  from 
fear  of  future  punishment  that  will  be  of  much  longer  duration 
and  more  intense. 

The  religious  sentiment,  however,  is  beneficial  to  the  community, 
and  exercises  great  inhibitive  and  educative  power,  in  the  sense  of 
restraining  individual  tendencies  in  the  interest  of  the  community. 
The  first  laws  were  religious,  and  their  purpose  was  to  restrain  the 
satisfaction  of  individual  instincts. 

If  it  be  true  that  some  men  feel  that  the  religious  emotion  has 
almost  spent  itself,  and  that  its  place  has  been  taken  by  another 
feeling  which  is  summed  up  in  respect  for  social  tendencies  and 
impulses,  it  evidently  proves  that  the  religious  sentiment  repre- 
sents a stage  in  the  moral  evolution  of  society,  and  tends  to  ’be 
replaced  by  the  feeling  of  duty. 

Tlie  religious  sentiment  is  the  ruled  line  along  which  the  moral 
sentiment  slowl}^  advances.  This  last,  which  is  the  highest  expres- 
sion of  sentiment,  the  fusion  of  all  the  emotions  and  of  all  the 
impulses,  has  arisen  and  has  become  a habit  of  consciousness  through 
rigid  religious  and  legislative  rules.  It  is  destined  to  become  a 
still  more  intrinsic  component  of  the  social  consciousness  now  in 
})rocess  of  evolution.  The  power  of  attention  and  the  imagination 


EMOTIONS  AND  SENTIMENTS 


363 


concur  in  it,  and  in  its  evolution  we  find  the  source  of  all  the  direc- 
tive power  of  man  in  his  social  relations.  Religious  sentiment, 
however,  tends  always  more  and  more  to  become  transformed  into 
a moral  consciousness  more  intimately  related  to  human  nature. 
The  testimony  of  men  who  refrain  from  ill-doing,  not  from  fear 
of  hell  or  because  of  the  commandments  of  religion,  but  because 
of  the  development  of  the  consciousness  of  their  duty  to  others, 
their  duty  not  to  cause  others  pain  they  would  not  care  to^  suffer 
themselves,  is  a sure  proof  of  the  evolution  of  the  moral  sentiment. 
It  is  in  this  way  that  morality  is  conceived  by  the  positivist  psycho- 
logist (Spencer,  Lewes). 

This  conception  inspires  the  greater  number  of  the  social  laws 
which  have  been  for  some  time  occupying  the  minds  of  legislators. 
These  have  for  their  basis  human  emotional  character,  highly 
evolved  in  the  direction  of  assuaging  the  pain  of  the  sufferer.  The 
law  of  evolution  of  the  sentiment  depends  upon  the  fact  that,  from 
being  purely  egoistic  in  the  early  days  of  humanity,  man  has  become 
egoistic-religious  in  successive  ages,  and  tends  to  rise  to  the 
dignity  of  a sentiment  of  humanity  and  of  duty  in  his  social  rela- 
tions. 

There  is  nothing  static  in  the  sentiments  and  emotions,  unless 
in  a very  temporary  sense.  Where  there  is  no  evolution  there  is 
regular  rhythm  of  an  order  of  emotions  in  organic  forms— hunger, 
sexual  needs,  etc.— but  all  states  of  consciousness,  emotions,  and 
sentiments  represent  a tendency  and  realize  the  concept  of  per- 
petual passage  upheld  by  James,  Bergson,  and  Rauh.  When  a 
falcon  sights  his  prey,  he  has  the  pleasurable  preperception  of 
satisfying  his  appetite,  and,  by  contrast,  the  fear  that  his  prey 
may  escape.  With  this  emotional  disposition  of  mind  there  is 
associated  the  tendency  to  combined  movements  directed  towards 
the  capture  of  the  prey,  and  the  prevention  of  its  escape.  Clearly, 
emotion  of  one  type  carries  with  it  emotion  of  another  type,  and 
is  always  translated  into  a tendency  to  movements,  which  remain 
rudimentary  or  are  executed  according  to  the  twofold  directive  of 
the  two  associated  emotions.  In  this  tendency  (associated  with 
emotion)  to  move  towards  what  is  pleasing,  and  to  get  away  from 
what  is  painful,  we  may  detect  desire,  which  is  a conscious  moment 
of  the  emotion  passing  into  action.  Preperceived  joy  is  a desire, 
and  actual  joy  moves  in  a plane  of  new  desires  and  new  tendencies. 
As  one  idea  brings  others  in  its  train,  so  one  emotion  is  transformed 
into  others,  and  the  tendencies  that  arise  from  judgments  and 
reasonings  emanate  only  from  sentiments  with  an  intellectual 
content. 

In  the  passage  of  certain  sentiments  into  others  we  sometimes 
fail  to  notice  the  intermediate  feelings  ; but  here,  too,  as  in  the  case 
of  ideas,  motion  is  perpetual. 

Static  emotion  is  always  morbid.  The  higher  sentiments 


364 


PSYCHIATRY 


(religious  and  moral),  which  appear  to  be  static,  resolve  themselves  ; 
through  endless  paths  of  conduct,  where  they  are  continually  meet- 
ing with  new  emotions.  Ecstasy  and  obsession,  which  are  pro-  | 
longed  states  of  joy  or  fear,  are  morbid  states.  The  organic  senti-  ' 
ments,  which  always  present  the  same  characteristics,  alternate  j 
with  one  another  in  almost  constant  rhythm.  Thus,  evolution  and  | 
movement  of  human  emotions  are  continuous.  The  passage  of  I 
egoism  into  self-sacrifice  is  often  nothing  more  than  the  enlarge-  | 
ment  of  the  personality,  seeking  its  pleasure  outside  of  itself  (Guyon,  j 
Rauh).  The  transformation  of  sensual  love  into  mystic  love  bears  1 
with  it  the  joy  peculiar  to  each — the  sensory  form  of  the  one  and  j 
the  aesthetic  form  of  the  other  emotion.  Pride  gives  rise  to  gener-  ■ 
osity  or  to  ingratitude,  based  upon  the  ruling  egoism.  The  de- 
pression consequent  upon  wounded  amour  propre  generates  hatred 
and  envy.  A believer,  like  Vaillant  or  Faure,  may  become  an 
anarchist  (Rauh,  De  la  methode  dans  la  Psychologic  des  Sentiments, 
1889),  and  a criminal  may  have  in  him  the  makings  of  a saint. 

The  vanity  of  the  hysteric  subject  is  a good  soil  both  for  the 
growth  of  rascality  and  for  the  development  of  enthusiasm  for  good 
causes,  leading  even  to  self-sacrifice  (Legrand  de  Saulle,  Jolly, 

P.  Janet,  and  many  others).  Faith  generates  the  emotion  of 
doubt,  and  sometimes,  in  degenerates,  it  originates  blasphemy. 
Ambition,  love,  and  pity  are  only  various  forms  of  egoistic  senti- 
ments, with  varying  proportions  of  altruism,  and  of  intellectual  ; 
representations.  On  the  one  hand,  we  have  in  altruism  the  physio-  ■ 
logical  fusion,  in  one’s  own  consciousness,  of  the  emotions  of  others 
— the  power  of  feeling,  through  sympathy,  what  others  feel,  in  the  ^ 
different  forms  and  degrees  of  pleasure  and  pain  ; on  the  other 
hand  we  have  the  greater  advantage  that  a man  acquires  through 
his  adaptation  to  the  demands  of  others. 

Altruism  also  assumes  various  forms.  Love,  originally  confined 
within  the  limits  of  instinct,  was  affected  throughout  the  Middle  . 
Ages  by  the  dominant  mysticism,  and  became  a passion  that  s 
assumed  in  literature  the  form  of  romanticism  ; while  within  the 
last  fifty  years  it  has  risen  to  the  recognition  of  equality  of  rights  ^ 
as  between  man  and  woman,  allowing  woman  to  develop  her  mental  * 
energies  in  all  directions,  even  where  she  comes  into  competition 
with  man.  In  this  case  we  may  speak  of  new  channels  opened  to 
the  love  of  man  for  woman. 

The  same  thing  has  been  observed  in  the  sentiment,  or  rather 
the  emotion,  of  pity.  To-day  pity  is  no  longer  the  giving  of  I 
humiliating  alms,  which  is  the  expression  of  individualism,  but  the  ; 
feeling  of  human  solidarity,  which  determines  the  collective  action  j 
of  society  towards  alleviating  human  suffering.  At  the  same  time,  f 
there  is  the  evolution  of  the  egoistic  sentiment,  which  is  at  the  |f 
basis  of  every  work  of  charity,  which  reaches  the  dignity  of  a col-  j) 
lective  social  defence.  If 


EMOTIONS  AND  SENTIMENTS 


365 


If,  when  I pass  a cripple  who  is  incapable  of  earning  subsistence 
for  himself,  I stretch  a hand  to  him  in  charity,  I am  then  obeying 
a sentiment  of  pity  ; but  at  the  same  time  I am  satisfying  a strong 
impulse  of  my  mind,  which  suffers  in  sympathy,  to  free  itself  from 
the  pain  caused  by  the  sight  of  suffering  in  others.  Now,  if  many 
men,  or  even  a whole  society,  unite  in  a common  effort  to  eliminate 
human  misery  from  the  world,  collecting  in  proper  establishments 
those  who  are  unable  to  work — cripples,  invalids,  and  the  poverty- 
stricken — and  procuring  for  them  a life  that  has  some  part  in  the 
comforts  of  the  rich,  individual  egoism  here  becomes  collective 
egoism,  and  assumes  the  form  of  social  defence.  Individual  charity, 
which  is  emotional  and  insufficient,  becomes  collective  charity — 
certainly  less  emotional  than  the  former,  but  very  much  better 
fitted  to  attain  the  objects  of  social  defence,  and  more  efficient  in 
procuring  for  invalids  and  cripples  at  least  a part  of  those  comforts 
that  are  enjoyed  by  the  healthy  and  strong. 

Here  discussion  might  arise  as  to  whether  these  are  true  emotions, 
for  some  would  maintain  that  true  emotion  is  particular,  and  never 
general.  But  if  we  consider  emotion  as  an  experience  of  the  proper 
self  in  relation  with  other  selves,  or  with  objects,  and  if  we  attribute 
to  emotion  the  content  of  the  images  to  which  the  relationship  is 
referable,  and  also  memory  (Ribot),  we  arrive  at  the  conviction  that 
the  mechanism  of  generalization  consists  in  the  fusion  or  synthesis 
of  individual  experiences  in  relation  to  the  external  world — fellow- 
beings,  animals,  and  things — together  with  an  increasing  degree  of 
intellectual  content.  Generalization  does  not  change  the  intrinsic 
character  of  the  fundamental  emotion  of  pleasure  or  pain.  It  is 
always  based  upon  egoism.  It  is  the  ego  enlarged,  and  with 
extended  relations  in  the  world.  Family,  fatherland,  religion, 
humanity,  enlarge  the  limits  of  one’s  proper  self.  Gratitude, 
which  is  one  of  the  highest  sentiments,  is  happiness  flowing  out 
from  one’s  own  mind  towards  the  person  on  whom  it  depends  ; 
it  is  a well-defined  reflex  of  causality,  based  on  pleasure. 

The  following  is  a brief  description  of  the  commonest  and  funda- 
mental emotions. 

We  have  already  said  what  are  the  somatic  notes  of  psychic 
pain  and  pleasure — sadness  and  joy. 

Sadness  is  negative  or  positive.  In  its  negative  form  we  can 
imagine  it  as  an  obstacle  to,  and  an  arrest  of,  our  habits  and  instincts, 
acting  through  representations  and  also  through  unconscious 
associations. 

The  subject  becomes  dejected  and  irresolute  ; he  lays  aside  the 
weapons  of  defence,  and  surrenders  to  the  misfortune  that  has 
assailed  him.  I believe  that  no  one  has  been  more  successful  in 
describing  negative  sadness  than  Leopardi  in  a letter  to  P.  Giordano. 
‘ Were  I to  go  mad  at  this  moment,’  he  writes,  ‘ I believe  that  my 
madness  would  take  the  form  of  sitting  with  an  amazed  look  always 


366 


PSYCHIA  TRY 


in  my  eyes,  my  mouth  open,  my  hands  between  my  knees,  and  | 
without  ever  laughing,  weeping,  or  moving  from  the  place  in  which  | 
I might  happen  to  be,  unless  I were  forced  to  do  so.  I have  no  i 
longer  the  strength  to  conceive  any  desire,  even  the  desire  of  death — ! 
not  because  I fear  it  on  any  account,  but  because  I can  see  no 
difference  between  death  and  this  life,  where  I have  nothing  left 
to  console  me,  not  even  grief.’ 

Positive  sadness  is  either  primary  or  else  follows  the  negative 
phase.  Its  characteristic  is  seen  in  the  case  of  the  man  who,  struck 
by  disaster,  figures  to  himself  all  the  ruin  and  misery  it  entails. 
Whilst  this  involves  disorganization  of  his  habits,  there  is  at  the 
same  time  the  commencement  in  him  of  a mental  effort  towards 
repairing  his  loss,  with  new  resources,  new  adaptations,  new  labour, 
new  habits  and  motive  tendencies  towards  active  life,  sometimes 
in  manifest  disagreement  with  the  habits  of  the  past,  but  tending 
to  restore  him,  in  view  of  the  enjoyment  that  they  promise. 

Active  sadness  tends  to  disappear,  being  gradually  driven  out 
by  new  adaptations  and  by  the  pleasure  derived  from  restorative 
work  ; but  let  it  become  inactive  or  inefficacious,  then  active 
becomes  confounded  with  negative  sadness.  If  the  difficulties  to 
be  overcome  are  too  great  for  the  strength,  the  sadness  persists, 
and  increases  with  fatigue.  As  somatic  pain  coincides  with  asthenia 
in  the  domain  of  physiology,  so  sadness  is  accompanied  with  dis- 
couragement in  the  domain  of  psychology.  In  passive  sadness  the' 
subject  abandons  himself  unresistingly  to  fate.  ‘What  good, 
is  there  in  working,  hoping,  planning,  or  taking  any  interest  in 
life  ?’  In  active  sadness,  however,  there  is  ideal  and  motor  super- ^ 
activity.  s 

Joy,  like  sadness,  is  both  positive  and  negative.  In  the  positive 
form,  as  when  a youth  passes  an  examination  that  assures  him  a; 
position,  or  when  a candidate  is  elected  to  an  office  that  offers  him? 
immediate  pleasure  and  opens  new  fields  to  his  talent,  we  have! 
new  adaptations,  and  a new  and  facile  direction  is  given  to  the'; 
instincts  and  habits  of  life.  A certain  number  of  past  habits  are 
at  once  discarded,  and  new  adaptations  are  easy  as  obstacles  are' 
removed.  To  take  an  example  from  Dumas,  an  individual  who 
comes  into  possession  of  a fortune  soon  has  preformed  representa- 
tions of  a number  of  new  habits,  as,  for  example  : ‘ I shall  allow 
myself  the  luxury  of  a carriage  ; my  clothes  will  be  made  by  the 
best  tailors  ; I shall  read  the  novel  of  the  day  ; I shall  educate  my 
children,’  etc.  i 

Here  there  is  a new  organization  of  states  of  consciousness  and 
new  syntheses,  all  formed  with  the  utmost  facility  (Paulham,, 
Dumont,  Dumas). 

The  negative  form  of  joy  corresponds  to  the  cessation  of  an 
obstacle  to  preformed  functions  ; in  other  words,  to  the  fulfilment 


EMOTIONS  AND  SENTIMENTS 


367 


of  a desire,  aspiration,  or  duty  that  has  stood  in  the  way  of  the 
regular  course  of  ideas  and  actions,  giving  rise  to  others  that  are 
painful.  Such  is  the  joy  of  the  student  who  passes  an  examination 
successfully,  after  long  preparation.  In  this  case  there  is  disorgani- 
zation of  the  habit  of  excessive  study  required  in  preparation  for 
the  examination,  and  free  indulgence  may  once  again  be  given  to 
old  habits  when  youthful  recreations  are  no  longer  prevented  by 
excessive  work. 

The  soldier  who  returns  home,  after  years  of  absence,  from  a 
war  in  China  is  seized  with  unspeakable  joy  when  he  meets  his 
mother  and  his  love.  They  run  towards  each  other  with  out- 
stretched arms,  glowing  face,  and  sparkling  eyes  ; they  embrace 
and  kiss  one  another,  giving  vent  to  tears  of  joy.  The  obstacle 
to  happiness  has  been  removed,  a long-standing  desire  satisfied  ; 
the  hardships  of  the  voyage  and  the  habits  of  life  at  sea  give  place 
to  the  genial  customs  of  family  life. 

x\s  is  evident  to  all,  the  majority  of  these  pleasurable  emotions 
are  not  distinctly  positive  or  negative.  There  is  prevalence  of  a 
mixed  type  in  so  far  as  in  most  cases  there  is  disorganization  of 
some  part  of  the  past,  and  some  impediment  is  removed.  In  the 
emotion  of  surprise  or  emotional  shock  of  Dumas  and  P.  Janet  we 
have  a form  of  positive  joy. 

Another  of  the  fundamental  emotions  is  fear.  In  this  particular 
type  we  find  almost  always  the  same  somatic  phenomena  as  were 
described  when  speaking  of  pain.  In  fact,  fear  is  only  pain  antici- 
pated, and  very  often  is  nothing  else  than  a form  of  pain.  In 
fear,  too,  there  is  a lowering  of  the  muscular  tone,  extending  to 
momentary  paralysis  of  the  voluntary  muscles  ; and,  on  the  other 
hand,  there  is  spasmodic  contraction  of  the  muscles  of  the  vessels 
and  of  all  the  organic  muscles  (Mosso),  with  this  difference,  that  in 
fear  the  phenomena  are  much  more  apparent  and  intense  than  in 
sadness.  An  individual  may  say  : ‘ I am  oppressed  ; I can  hardly 
bear  my  pain  but  fright  and  terror  are  paralyzing  ; they  petrify 
and  deprive  of  speech.  People  fall  to  the  ground  paralyzed  by  fear. 
Cries,  trembling,  sudden  starts,  paralysis  and  convulsions,  form 
part  of  the  somatic  picture  of  intense  fear.  The  strong  spasmodic 
contraction  of  the  cutaneous  vessels  produces  shivering,  whence  the 
common  saying  : ‘ My  blood  froze  in  my  veins.’  Cold  sweats, 
sometimes  rapid  whitening  of  the  hair,  diminution  or  disappear- 
ance of  the  secretions,  constriction  of  the  chest,  anguish,  difficulty 
in  breathing,  and  palpitation,  with  weak  pulse  or  even  paralysis  of 
the  heart,  leading  to  sudden  death  from  fear,  are  phenomena  of  the 
intense  forms  of  this  emotion. 

Spasmodic  contractions  of  the  organic  muscles  are  much  more 
frequent  in  fear  than  in  sadness.  In  fact,  it  is  often  the  case  that 
people  drench  themselves  with  urine  through  fear.  Lange  remarks 


368 


PSYCHIATRY 


ironically  that  ‘ when  the  combat  is  approaching,  young  conscripts 
are  often  obliged  to  leave  the  ranks,  and  if  they  remain  in  the  line 
they  are  not  always  agreeable  neighbours.’  Starting  eyes,  dilated 
pupils,  hair  on  end,  all  of  which  phenomena  are  dependent  on 
involuntary  contractions  of  the  respective  muscles,  complete  the 
outlines  of  the  somatic  picture  of  fear. 

In  its  slighter  degrees,  fear  may  give  rise  to  motor  phenomena 
of  another  nature— for  example,  flight  or  defensive  movements. 
These  movements  are  not  the  expression  of  real  exaltation  of  the 
motor  energies,  because  fear  is  weakening  in  all  its  grades  ; they 
are  rather  stereotyped  and  instinctive  movements  that  at  no  time 
represent  the  organization  of  new  habitudes  or  the  formation  of 
syntheses,  but  always  maintain  the  same  character,  the  same 
form,  and  the  same  direction.  Sometimes  they  are  completely 
unconscious,  and  this  is  the  explanation  of  those  mad  flights  over 
many  miles,  kept  up  after  all  danger  has  passed,  without  any 
feeling  of  fatigue. 

In  still  slighter  forms,  fear  is  confounded  with  pain,  of  which 
it  is  only  an  anticipation.  The  candidate  who  fears  that  he  will 
be  plucked  in  his  examination,  the  traveller  who  is  afraid  of  persons 
lying  in  wait  for  him,  the  mothor  who  fears  that  her  sick  child  will 
die,  the  soldier  called  to  arms  in  time  of  war,  the  lover  afraid  that 
someone  will  carry  off  his  beloved,  all  afford  examples  of  pain  antici- 
pated by  imagination. 

In  an  even  slighter  degree  still,  the  element  of  fear  is  present 
in  all  actions  directed  by  some  desire  or  aspiration,  and  hindered 
in  their  realization  by  some  difficulty  to  be  overcome.  Here  the  , 
fundamental  law  of  contrast  comes  into  play,  being  naturally 
formed  by  association  between  the  desire  to  succeed  and  the  risk 
of  failing. 

Fear  attaches  to  the  unknown  and  to  all  that  is  inexplicable  in 
the  present  or  the  future  with  regard  to  everyone,  in  the  intel- 
lectual and  moral  sphere,  in  our  cosmic  and  in  our  social  relations 
(mysticism,  Tanzi). 

Fear  diminishes  in  proportion  as  our  notions  increase,  and  as 
our  power  of  perception  of  the  environment  in  which  we  live  is 
sharpened.  All  states  of  emotion  based  on  fear  induced  by  religious 
prejudices  tend  to  disappear,  and  to  be  replaced  by  states  of  much 
less  intensity,  closely  connected  with  the  struggle  for  life  ; while 
these  latter  also  lose  intensity  with  the  increase  of  human  activities 
and  the  facilitation  of  the  perception  of  the  environment  and  new 
adaptations.  In  this  way  the  negativism  of  fear  becomes  diminished, 
even  before  the  open  grave,  and  the  value  of  life  increases  through 
efficient  activitv. 


A very  common  emotion  is  anger,  which,  were  we  to  be  guided 
in  this  matter  by  the  examination  of  the  somatic  phenomena  alone. 


EMOTIONS  AND  SENTIMENTS 


369 


would  appear  to  bear  the  same  relation  to  joy  as  fear  does  to  pain. 
We  have  throughout  the  same  somatic  appearances  as  in  joy — 
dilation  of  the  small  vessels,  increased  cutaneous  circulation, 
heightened  colour,  swelling  of  the  face  and  neck,  flashing  eyes,  etc. 

In  common  parlance,  we  have  ‘ The  blood  rushes  to  his  head,’  and 
‘ When  he  is  vexed  he  becomes  red  and  swollen  like  a turkey-cock.’ 
These  are  popular  similes,  but  they  express  the  demonstrable  fact 
of  the  increased  cutaneous  circulation.  We  observe,  however,  at 
the  first  glance,  a difference  between  anger  and  joy.  In  the  latter 
emotion  the  swelling  of  the  face  and  the  neck  is  not  so  pronounced 
as  in  anger,  neither  is  there  such  turgidity  of  the  veins  of  the  fore- 
head and  the  neck — a consequence  of  the  cries,  strong  and  pro- 
longed expirations,  and  tumultuous  violence  of  muscular  contrac- 
tion, preventing  the  regular  discharge  from  the  veins  of  the  head. 
In  anger  the  excito-motor  tension  is  enormous,  and  generates  rapid, 
energetic,  multiple,  and  often  inco-ordinated  movements.  In  the 
stronger  forms  of  anger,  such  as  fury,  the  movements  are  violent 
in  a high  degree.  The  voice  is  raised,  speech  rapid  and  threatening, 
sometimes  confused  by  overhaste,  the  arms  are  held  aloft  or  brought 
forward,  the  feet  stamp,  the  eyes  are  staring,  the  forehead  is  deeply 
furrowed,  the  angles  of  the  mouth  are  turned  upwards  as  if  to  grind 
the  teeth,  or  the  lips  are  bitten  until  they  bleed,  while  all  obstacles 
are  broken  to  pieces  or  thrust  out  of  the  way  with  much  noise  and 
violence.  Those  are  the  principal  signs  of  anger  and  of  fury. 

All  the  susceptibilities  are  diminished  in  a fit  of  anger.  The 
common  expressions  ‘ blinded  by  rage,’  ‘ deaf  with  fury,’  are  true 
in  the  sense  that  slight  noises  are  not  noticed  by  a man  in  fury, 
and  the  field  of  his  vision  is  necessarily  restricted,  while  in  the 
same  way  tactile  sensibility  and  sensibility  to  pain  are  lessened, 
if  we  may  judge  from  the  fact  that  in  the  heat  of  a quarrel  a wounded 
man  does  not  at  once  notice  the  pain  of  his  wounds. 

We  have  seen  that  the  emotions  just  described,  and  which  I 
might  call  primary  and  fundamental,  have  a large  number  of 
accompanying  physical  symptoms  constituting  an  integral  part  of 
the  emotion,  and  so  fully  do  they  enter  into  its  constitution  that 
some  psychologists  interpret  emotion  as  simply  the  consciousness 
of  the  somatic  phenomena  (vide  supra). 

We  have  referred  to  the  bulbar  and  cortical  origin  of  these 
emotional  phenomena  of  circulation,  respiration,  and  secretion, 
but  we  cannot  refrain  from  some  short  notice  of  the  central 
mechanism  of  all  the  phenomena  of  the  expressions  and  attitudes 
of  the  physiognomy,  as  these  take  so  great  a part  in  emotion. 
We  must  distinguish  two  orders  of  facts  : first,  the  voluntary  ex- 
pressions by  which  man  and  the  lower  animals  communicate  to 
their  kind  their  various  states  of  mind — their  different  attitudes, 
their  various  movements,  their  voices,  or  their  speech — but  it  is 

24 


PSYCHIATRY 


37<^ 

not  with  these  that  we  shall  deal  here  ; and,  second,  those  other 
motor  phenomena,  also  reflecting  particular  states  of  mind,  such 
as  the  movements  expressive  of  pain,  fear,  hatred,  anger,  shame, 
weeping,  laughter — movements  which  are  independent  of  the  will, 
and  are  based  neither  on  habit  nor  on  imitation. 

Bechterew  holds  that  the  second  class  of  expressive  movements 
depends  upon  an  innate  organization,  and  manifests  itself  through 
a particular  mechanism  that  has  no  direct  relation  with  the  system 
of  nerve-paths  serving  for  the  transmission  and  execution  of 
voluntary  movements  (‘  Die  Bedeutung  der  Sehhilgel  aiif  Grund  von 
experimentellen  und  pathologischen  Daten,^  Arch.  /.  Path.  u.  Phys., 
Von  Virchow,  1887).  Such  movements  are  involuntary.  They  are 
certainly  noticed,  and  may  be  imitated,  but  their  mechanism  is 
distinct  from  that  of  the  voluntary  movements.  They  are  ‘ reflex 
movements  of  expression,’  and  may  also  be  produced  in  animals 
from  which  the  brain  has  been  removed,  and  in  states  of  uncon- 
sciousness due  to  chloroform,  hysteria,  etc.  ; they  may  also  be 
modified  or  suppressed  by  the  will. 

The  central  mechanism  of  these  particular  reflexes,  innate 
movements  of  expression,  has  its  seat  in  the  thalamus  opticus, 
according  to  Bechterew,  Meynert,  and  Flechsig.  Kolliker  has 
constructed,  after  a fashion,  the  diastaltic  arc  of  these  reflexes. 
He  admits  that  some  of  these  paths  go  from  the  thalamus  to  the 
red  nucleus,  and  thence  to  the  cerebellum  ; others  from  the  thalamus 
to  the  internal  capsule,  the  cerebral  peduncle,  and  the  pons  Varolii  ; 
others,  finally,  originating  also  in  the  thalamus,  proceed  through 
the  lamina  medullaris  lateralis  of  the  thalamus,  and  through  the 
stratum  fenestratum,  then  pass,  like  the  other  efferent  bundles, 
into  the  internal  capsule  and  the  peduncle,  and  continue  their  way 
(possibly  in  the  reticular  formation,  as  Flechsig  thinks). 

Clinical  observations,  like  the  results  of  experiments,  tend  to 
confirm  the  idea  that  the  innervation  of  emotional  expression  is  ^ 
independent  of  the  will.  Anencephalics  are  able,  for  a considerable 
time,  to  cry  out  and  to  mimic  the  attitudes  of  emotion.  In  my  ' 
clinique  I have  an  idiot,  microcephalic  in  the  highest  degree,  who  ; 
cannot  speak  at  all,  and  yet  expresses  the  pleasure  of  eating  and  | 
drinking  by  mimicry,  sometimes  very  lively.  In  not  a few  cases  ! 
the  mimicry  is  exaggerated,  either  through  irritation  of  the  centre  1 
of  involuntary  movements,  the  thalamus  opticus,  by  a focus  in  its 
proximity,  or  through  interruption  of  the  paths  connecting  the 
thalamus  opticus  with  the  cortical  centres  of  inhibition  (Brissaud, 
Mingazzini).  Large  cortical  and  subcortical  foci,  interrupting  the 
paths  of  the  corona  radiata  cortico-thalamica,  and  capsulary  foci 
irritating  the  thalamus,  but  leaving  it  entire,  or  almost  so,  along 
with  its  efferent  communications,  cause  spasmodic  laughter  and 
weeping,  and,  in  general,  an  exaggerated  expression  of  emotion.  , 

1 he  observations  of  Stromayer,  Romberg,  Nothnagel,  Gowers, 


EMOTIONS  AND  SENTIMENTS 


371 


Rosenbach,  and  others,  offer  further  proof  of  the  independence  of 
the  mechanism  of  emotion  of  that  upon  the  will,  because  there  may 
be  isolated  paralysis  of  the  emotional  mimicry  without  paralysis 
of  the  voluntary  movements.  If  there  is  an  affection  of  the  upper 
part  of  the  pons  Varolii,  through  which  the  fibres  of  mimicry  pass, 
we  may  have  paralysis  exclusively  of  the  mimicry,  since  the  voli- 
tional paths  (pyramidal)  run  in  the  lower  parts  of  the  pons.  We 
have  already  noted  the  experiments  of  Bechterew,  Bochefontaine, 
Munk,  Ostankow,  and  Mislawski,  proving  the  existence,  on  the 
somaesthetic  zone,  of  centres  for  the  movements  of  the  face,  the 
larynx,  respiration,  circulation,  and  tears,  so  that  consequently 
that  area  might  be  considered  as  the  seat  of  the  movements  expres- 
sive of  emotion,  especially  weeping  and  laughter. 

Clinical  observations,  however,  do  not  confirm  this  supposition. 
Bilateral  destruction  of  the  Rolandic  zone  paralyzes  the  voluntary 
movements  of  the  face,  but  not  the  movements  expressive  of 
emotion.  Now,  as  the  existence  of  physiognomic  centres  in  the 
thalamus  opticus  appears  to  have  been  proved,  it  is  much  more 
logical  to  admit  that  the  cortical  centres  are  volitional,  and  that 
the  centres  in  the  thalamus  are  intended  for  the  involuntary  ex- 
pression of  emotions.  This  view  is  the  one  best  supported  by  facts. 
Brissaud,  Monakow,  and  Mingazzini  agree  upon  this  theory,  with 
some  modifications.  According  to  these  observers,  the  thalamus 
opticus  is  the  centre  of  movements  co-ordinated  for  the  physiog- 
nomic expressions  of  emotion  ; while,  according  to  Brissaud,  the 
frontal  lobe  is  the  psychic  and  regulative  centre  of  the  function  of 
the  thalamus.  The  anterior  tract  of  the  internal  capsule  would 
represent  the  path  by  which  the  moderating  influence  of  the  cere- 
bral mantle  is  exercised  upon  the  thalamus  opticus.  All  lesions 
of  this  tract  of  the  capsule,  by  withdrawing  the  thalamus  from  the 
inhibition  of  the  mantle,  give  rise  to  exaggerated  emotive  expres- 
sion, and  especially  to  spasmodic  weeping  and  laughter,  provoked 
by  stimuli  coming  through  the  sensory  paths  or  from  the  sensory 
zones,  which  are  in  connection  with  the  thalamus  (Monakow). 

The  part  taken  in  the  expression  of  emotion  by  the  medulla 
oblongata  is  shown  by  the  observations  of  Oppenheim,  as  well  as 
by  our  knowledge  of  the  anatomical  relations  of  the  nuclei  of  the 
medulla  oblongata  with  the  thalamus.  It  is  not  improbable  that 
the  bulb  represents  one  of  the  centres  Stationed  along  the  paths 
for  expression  of  the  emotions. 

From  the  researches  here  recorded  there  emerges  once  again 
the  coexistence  of  two  facts  in  emotion  : emotional  representa- 
tions, of  cortical  origin  ; and  emotional  expressions,  originating  in 
the  thalamus,  and  perhaps  also  in  the  bulb.  The  expression  may 
be  reproduced  by  peripheral  stimuli  without  analogous  emotional 
representations,  and,  on  the  other  hand,  the  emotion  may  be  con- 
cealed by  the  restraining  power  of  the  mantle  over  the  emotive 

24 — 2 


372 


PSYCHIATRY 


reflexes  of  the  thalamus.  This  double  series  of  facts  renders  the 
theory  of  James-Lange  still  more  uncertain. 

The  Pathology  of  the  Emotions  comprises  the  greater  part 
of  the  mental  maladies.  Every  one  of  these,  as  a symptomatic 
complex  or  syndrome,  is  to  be  considered  also  from  the  side  of  the 
emotions,  which  are,  in  most  cases,  essential  components  of  the 
malady.  From  this  fact  it  becomes  clear  that  we  cannot  under- 
take here  a methodical  study  of  the  pathology  of  the  emotions. 
For  the  most  part  it  is  reserved  for  the  third  section  of  this  work. 
Here  we  limit  ourselves  to  stating  only  the  general  conception  of 
the  physiology  and  pathology  of  the  emotions,  a conception  that 
will  be  completed  in  the  study  of  the  individual  forms  assumed  by 
mental  disorder.  This  appears  all  the  more  necessary  as  every 
day  we  are  becoming  more  certain  of  the  important  part  played 
by  the  emotions  in  the  genesis  and  development  of  those  mental 
maladies  that  were  formerly  considered  to  be  of  intellectual  origin 
(Ferrari,  Rivista  Sperim.  di  Freniatria,  1901). 

Morbid  Depression. — Moral  pain,  prolonged,  and  dispropor- 
tionate to  the  cause  producing  it,  is  morbid.  It  passes  through  all 
grades,  from  simple  bad  humour  to  the  passive  and  the  agitated 
or  active  form  of  melancholy. 

Along  with  the  gloomy  disposition  there  is  fear,  suspicion, 
negativism,  tedium,  asthenia,  inefflcacy.  The  sadness  that  allows 
the  subject  still  to  hold  his  own  place  on  the  chess-board  of  common 
life  is  the  constant  note  of  neurasthenia,  of  whatsoever  form  and 
degree,  whether  inherited  or  acquired.  Asthenia  and  sadness  are 
two  manifestations  of  the  same  state.  As  sadness  is  always  accom- 
panied by  asthenia,  so  it  is  very  seldom  that  asthenia  is  not  clothed 
in  vestments  of  sadness.  Whenever  the  somatic  ego  is,  or  is  thought 
to  be,  weakened,  and  incapable  of  bearing  the  shock  of  the  cosmic 
agencies,  or  whenever  the  social  ego  experiences  insufficiency  in  its  i 
human  relations,  depression  invades  the  mind,  and  expresses  itself  | 
in  pathological  forms,  among  which  we  note  humility,  modesty,  j 
shamefacedness,  incertitude,  suspicion,  fear,  ill-humour,  and  the  i 
pessimism  that  produces  the  victims  of  the  most  pronounced  forms  I 
of  melancholy.  A particular  type  of  this  group  is  afforded  by  the  J 
timid  subject.  | 

Timidity  is  an  emotion  composed  of  mingled  fear  and  shame, 
determined  by  particular  circumstances.  The  emotion  comprises 
a complex  state  of  disturbance,  confusion,  embarrassment,  hesita- 
tion, fear,  scruples,  modesty,  accompanied  by  organic  manifesta- 
tions, such  as  palpitation  of  the  heart,  anguish,  cold  sweats,  tremors, 
and  reddening  of  the  face.  The  circumstances  that  give  rise  to  j 
this  complex  of  phenomena  may  be  summed  up  as  the  presence  of  | 
another  human  being.  It  is  only  in  the  presence  of  his  fellows,  as  li 
Hartenberg  says  in  his  valuable  monograph  (Les  Timides  et  la\ 


EMOTIONS  AND  SENTIMENTS 


373 


Timiditc,  Paris,  1901),  that  the  timid  subject  is  disturbed,  colours 
up,  suffers  anguish,  trembles,  and  palpitates.  He  is,  above  all,  an 
ego-altruistic  sensitive  subject ; he  is  afraid  of  compromising  his 
own  dignity,  and  of  giving  any  offence  to  the  susceptibilities  of 
others.  From  this  there  arises,  on  the  one  hand,  the  analytical 
perspicacity  of  the  timid  subject  in  penetrating  the  sentiments  of 
others,  so  as  to  avoid  offending  or  opposing  them  in  any  way 
(Dugas) ; and,  on  the  other  hand,  his  exaggerated  scrupulosity  in 
social  relations,  leading  him  to  take  every  care  to  avoid  shocking 
those  with  whom  he  comes  in  contact. 

Shame  is  allied  to  fear  in  the  timid  subject.  This  is  a very 
complex  emotion,  of  which  the  degrees  are  chastity  and  modesty. 
It  has  its  own  characteristic  expression  in  reddening  of  the  face, 
with  a slight  acceleration  of  the  heart-beats.  Shame  is  a cause  of 
great  torture.  From  the  youth  who  hesitates  to  enter  a drawing- 
room because  he  imagines  that  everyone  is  looking  at  him,  and  is 
afraid  that  others  may  notice  some  fault  in  his  behaviour,  to  the 
orator  who  fears  that  words  will  fail  him  or  serve  him  badly,  there 
is  a gradation,  in  which  we  find  a predominance  of  weak  subjects 
who  are  ashamed  of  trifles  and  always  incapable  of  managing  their 
own  affairs. 

Emotive  sensitiveness  induces  a certain  hypertrophy  of  egoism, 
giving  rise  to  an  exaggerated  amour  propre,  and  this  is,  at  bottom, 
the  danger  threatening  the  spiritual  ego,  and  especially  the  social 
ego,  containing  as  it  does  the  latent  germ  of  pride,  that  develops 
rapidly  in  certain  circumstances. 

Timidity  is  the  cause  of  ereutophobia,  of  which  we  have  already 
spoken,  and  of  other  forms  of  neurosis. 

The  neurosis  of  anguish  of  Freud  {g  Angstneurosef  Neuro- 
logisches  Centralhlatt,  1895)  and  of  Hartenberg  {Ea  Nevrose 
cCangoisss,  Paris,  1902)  is  characterized  by  great  algesic  irrita- 
bility of  the  ego,  with  prevailing  susceptibility  to  noises  (aural 
hyperassthesia),  while  the  mind  is  directed  upon  the  emotion  of 
fear.  This  particular  condition  sharpens  the  power  of  attention, 
in  the  sense  that  it  gives  rise  to  a preoccupation  about  some 
imminent  harm  or  danger,  the  nature  of  which  varies  much  in 
different  subjects.  Most  of  the  cases  are  those  of  women  pre- 
occupied about  their  husbands  or  children.  Thus,  if  a cough  is 
heard,  they  instantly  dread  a serious  affection  of  the  lungs  (in  the 
husband  or  child)  ; a ring  at  the  door-bell  rouses  strong  apprehen- 
sion of  sad  news  ; a thunderstorm  brewing  and  announcing  itself 
by  the  first  clap  awakens  great  fear  of  possible  harm  and  danger  ; 
any  unusual^  sensation  in  the  chest  throws  them  into  a state  of  the 
utmost  consternation  through  fear  of  consumption  ; if  a son  is  late 
in  coming  home,  they  are  greatly  agitated,  picturing  him  beset  by 
all  the  dangers  of  this  world.  Very  frequently  they  are  afraid  of 
losing  their  sanity,  in  which  case  they  have  an  absolute  dread  of  the 


374 


PSYCHIATRY 


alienist,  and  the  mere  mention  of  lunatics,  insanity,  or  doctors  of 
insanity,  throws  them  into  a state  of  indescribable  anguish. 

This  condition  of  affairs  may  be  episodical  in  a neuropathic  con- 
stitution, but  most  frequently  it  constitutes  a true  morbid  form. 
The  sufferer  is  continually  tormented  in  every  phase  of  his  life  by 
the  phenomena  above  described.  With  Hartenberg,  however,  I 
must  admit  a neurosis  of  pure  anguish,  which  is  frequently  met 
with  ; also  attacks  of  anguish  in  neurasthenia  and  hysteria. 

Some  of  these  repu'esentatives  of  painful  hyperemotivity  occa- 
sionally show  ready  but  disproportionate  and  violent  reaction. 

It  is  a short  step  from  the  neurosis  of  anguish  to  obsession  by 
fear.  In  these  cases  of  obsession  we  have  always  an  irrational  fear, 
produced  at  one  time  under  circumstances  that  would  naturally 
cause  it,  and  exaggerated  by  imagination,  and  by  the  direction  of 
the  attention  to  the  state  of  emotion  that  already  occupies  the 
consciousness.  It  is  important  to  note  that  the  fact  determining 
this  state  of  emotion  has  existed,  either  really  or  in  the  form  of  a 
representation.  The  strong  repugnance  felt  on  coming  in  contact 
with  dirt  in  any  form,  the  shudder  on  seeing  a dirty  person  or 
thing,  give  rise  to  a powerful  emotion  that  causes  the  subject 
constant  fear  of  defiling  himself  by  touching  anything  at  all.  He 
accordingly  takes  measures  to  avoid  contact  of  any  sort,  and  should 
a contact  occur  it  gives  rise  to  a strong  and  exaggerated  emotion,  just 
as  if  he  had  really  been  defiled. 

If  a predisposed  or  hypersensitive  individual,  overtaken  by  a 
thunderstorm,  with  lightning  and  a deluge  of  rain,  be  overcome  b}^ 
intense  fear  of  the  danger  he  runs  ; or  if,  when  he  is  at  home,  a 
thunder-bolt  should  fall  in  his  vicinity  with  great  noise,  destroying 
something  or  killing  somebody,  there  will  remain  with  him  an 
emotive  potential  of  fear,  related  to  the  representations  of  the 
causes  that  first  determined  it,  so  that  either  the  mere  representa- 
tion or  the  approach  of  the  tempest  produces  the  same  sense  of 
emotion,  and  always  with  the  same  intensity.  This  is  sometimes 
so  irrational  as  to  constitute  a veritable  morbid  fact.  The  subject 
turns  pale,  suffers  from  tremors,  diyness  of  the  mouth,  visceral 
movements,  diarrhoeic  discharges,  sometimes  nausea,  palpitation, 
oppression,  or  even  a fit  of  real  anguish  (siderophohia). 

If  an  individual  has  suffered  from  terror,  or  something  extremely 
disagreeable  in  his  own  house,  he  will  have  a horror  of  that  house 
that  is  sometimes  invincible  (oiko phobia  of  Verga,  Salemi-Pace, 
and  others). 

The  fear  of  darkness  owes  its  origin  to  the  tales  told  to  infants 
of  hideous  beings — werewolves,  witches,  fairies,  evil  spirits,  all  of 
whose  doings  occur  by  night.  It  is  through  unconscious  associa- 
tion that  many  children  and  5’oung  people  are  afraid  of  night,  as 
the  season  of  evil  doing,  and  there  does  not  seem  to  be  much  proba- 
])ility  in  tlie  li3q:>othesis  of  Fere,  who  makes  this  emotion  depend 


EMOTIONS  AND  SENTIMENTS 


375 


on  the  diminution  of  vital  activity  due  to  the  lack  of  that  physio- 
logical excitant — light. 

The  fear  of  being  buried  alive  (tapho phobia)  and  the  fear  of 
being  deformed  {dysmorpho phobia,  Morselli)  are  merely  reproduc- 
tions of  preformed  emotions  and  images.  We  shall  have  to  speak 
of  these  at  length  in  the  third  part  of  this  work. 

Recently  I have  observed  two  cases  of  ereutophobia,  and  the 
result  has  had  not  a little  influence  on  my  adverse  opinion  of  the 
somatic  theory  of  the  emotions.  One  of  these  was  a young  man 
of  about  twenty-four  years,  rather  intelligent,  but  hypersensitive, 
excitable,  and  belonging  to  a family  sufl[ering  from  neuropathic 
heredity.  For  a long  time  he  had  been  subject  to  flushing  of  the 
face  and  a feeling  of  fulness  in  the  head,  with  a slight  clouding  of 
consciousness  under  the  action  of  even  insignificant  impressions  ; 
yet  he  had  never  had  any  preoccupation  about  this,  nor  had  he 
ever  been  troubled  about  or  ashamed  of  his  blushing,  until  one  day 
a friend  told  him  that  he  reddened  too  easily. 

From  that  time  he  had  no  longer  any  peace.  He  suffered  un- 
bearable anguish  whenever  he  happened  to  meet  any  person,  even 
one  he  knew  well,  or  when  he  found  that  someone  was  looking  at 
him.  The  same  thing  occurred  whenever  he  had  to  meet  in  business 
even  persons  with  whom  he  had  had  frequent  dealings.  In  this 
case  it  was  clear  that  it  was  not  the  fact  that  he  was  conscious  of 
the  reddening  of  the  face  and  the  fulness  in  the  head  that  gave 
rise  to  the  emotional  state,  but  his  belief  that  his  blushes,  when 
noticed  by  others,  compromised  him,  or  at  least  compromised  his 
dignity  as  a man.  Here  also,  therefore,  the  psychic  component 
was  clearly  the  indispensable  condition  in  the  production  of  the 
emotion,  and  hence  it  is  evident  that  the  somatic  component  alone 
does  not  produce  the  emotion,  even  though  it  be  felt.  The  fear  of 
blushing,  as  has  been  noted  by  Bechterew,  Pitres,  and  Regis, 
causes  extraordinary  anguish,  and  the  sufferers  indulge  in  the  idea 
of  suicide. 

Whatever  be  the  intellectual  or  representative  content  of  such 
emotions — and  in  their  variety  these  emotions  may  extend  to  all 
the  objects  and  all  the  positions  that  may,  by  any  accident  what- 
soever, provoke  an  emotion  of  fear — there  always  coincide  with 
them  the  physiological  mutations  of  the  emotion  of  fear  : precordial 
distress,  disturbance  of  the  respiration,  muscular  relaxation,  pallor, 
great  frequency  of  heart-beats,  etc. 

Fear  is  an  attribute  of  the  weak,  who  are  afraid  of  every  new 
thing.  For  them  habituation  is  the  indispensable  condition  of 
existence.  They  are,  as  Lombroso  happily  characterizes  them, 
misoneists  par  excellence.  Every  new  adaptation  presents  to  them 
almost  insurmountable  difficulties,  and  becomes  an  object  of  fear. 
Of  course,  it  must  be  understood  that  sometimes,  as  Sighele  observes, 
these  weak  subjects  may  also  be  fond  of  novelty,  but  in  this  case 


376 


PSYCHIATRy 


the  novelties  they  hanker  after  are  those  that  present  no  difficult}^  | 
as,  for  example,  the  love  of  new  clothes  or  new  fashions.  It  is  fear  | 
that  keeps  many  from  giving  expression  to  their  own  opinions,  or  i 
from  taking  up  a decided  attitude  in  political,  religious,  commercial,  | 
or  industrial  movements.  What  we  term  individual  indifference, 
or  the  indifference  of  a whole  race,  is  often  the  product  of  a lack 
of  positive  and  determinative  emotions  ; or  it  is  produced  by  fear, 
which  is  paralyzing.  In  these  cases  the  subject  is  urged  on  paths 


by  fortune. 

A condition  of  anguish  is  also  produced  by  the  state  of  doubt. 
Physiologically,  the  choice  between  two  ways — to  do  or  not  to  do  | 
— when  the  effects  of  the  action  do  not  appear  clear,  and  especially 
when  a fortune  is  at  stake,  or  when  the  personality  in  toto  or  one 
of  its  important  factors  is  involved,  causes  anguish  from  the  diffi-  . 
culty  attaching  to  the  choice.  This  suffering  is  shorter  in  duration  * 
in  proportion  as  the  judgment  is  more  rapid  or  action  readier.  In 
the  morbid  state,  on  the  contrary,  doubt  unceasingly  returns  to  I 
torment  the  consciousness  with  regard  to  matters  that  have  been  i 
seriously  studied,  or  about  questions  of  faith  that  were  never  a i 
subject  of  discussion,  or  even  all  the  acts  of  life,  and  particularly  I 
the  most  trifling.  It  is  chiefly  theological  doctrine  or  religious 
faith  that  is  harassed  by  doubt  in  indiVflduals  who,  for  a long  time, 
had  never  a doubt  at  all. 

A Jesuit  of  great  mental  power,  and  of  more  than  ordinary  | 
culture,  who  had  been  for  many  years  a professor  of  theology  at 
home  and  abroad,  and  who  was  long  conflned  in  the  asylum  for  a 
form  of  circular  insanity,  had  from  his  youth,  including  the  years  ! 
when  he  was  a student  and  had  won  universal  esteem,  suffered 
from  tormenting  doubt  about  the  theological  doctrines  that  he  : 
taught,  and  of  whose  truth  he  was  convinced.  Pie  was  continualh^  ; 
harassed  by  doubts  in  matters  of  faith.  ; 

In  other  cases  doubt  does  not  act  upon  the  held  of  intellect,  but  i 
affects  the  consciousness  of  all  the  actions  performed.  Sometimes  ' 
it  appears  to  be  nourished  by  defective  perception  and  judgment, 
as,  for  example,  in  the  terrible  doubt  some  people  have  of  com-  ’ 
promising  themselves,  or  of  having  already  compromised  them-  ; 
selves,  by  putting  their  signature  to  a letter,  deed,  or  contract.  ‘ 
In  other  cases  it  appears  to  be  rather  a defect  of  memoiy,  as  when  j 
an  individual  is  seized  by  strong  anguish  after  posting  a letter,  i 
being  in  doubt  whether  he  has  signed  it  ; or  when  he  is  constrained  | 
to  rise  from  bed  a second  or  a third  time  to  go  and  see  that  the 
house  door,  which  had  been  opened  a little  previously,  has  been 
properly  closed.  In  all  these  cases  the  chief  defect  is  of  muscular 
or  kiucTsthetic  memory,  because  it  is  not  that  the  sufferer  does  not 
remember  tlic  signing  of  the  letter  or  the  closing  of  the  door,  but 
his  recollection  is,  as  it  were,  an  abstraction.  It  seems  to  lack  the 


I 


EMOTIOyS  AND  SENTIMENTS 


377 


kinaesthetic  component  of  completed  action,  which  identifies  the 
person  with  the  action  and  with  the  recollection  of  it. 

A state  of  anguish  is  also  produced  by  the  disappearance  of  the 
affections  from  consciousness.  Most  instances  are  furnished  by 
women,  who  are  overcome  by  profound  sadness  because  they  no 
longer  feel  the  affections  of  wife  or  mother.  ‘ My  sole  joy,’  said  a 
lady,  ‘ was  the  very  great  affection  that  I had  for  my  children  ; I 
lived  on  that,  and  it  was  the  greatest  treasure  of  my  life  : but  now 
I have  no  affection  at  all.  I feel  that  there  is  a great  void  in  my 
mind,  and  I do  not  know  what  reason  I have  for  living  any  longer.’ 
That  lady  had  a tendency  to  suicide,  and  the  reason  of  it  was  that 
her  personality,  the  spiritual  ego,  had  been  much  diminished  and 
disintegrated  by  the  simple  fact  that  its  most  active  component 
had  disappeared  from  consciousness. 

Suspicion  is  simply  preperceived  fear,  and  is  due  to  defect  of 
perception  and  of  the  power  of  attention,  both  of  these  being  in 
inverse  ratio  to  the  fear,  which  is  always  the  expression  of  weakness 
and  inferiority,  whether  it  be  in  consciousness  or  on  the  threshold 
of  consciousness,  under  the  form  of  suspicion.  As  an  intermediate 
link  in  the  psychic  processes  leading  to  action  in  social  relations, 
it  may  be  considered  as  a physiological  fact,  provided  that  it  does 
not  stop  action  or  lead  it  astray  owing  to  fear.  It  arises  from  the 
difficulties  that  every  man  meets  with  in  pursuing  his  personal 
aims  in  society,  as  these  difficulties  oppose  innumerable  resistances 
to  his  efforts.  Physiological  suspicion  invites  attention  to,  and 
investigation  of,  every  position  that  threatens  loss  or  danger,  and 
it  disappears  with  the  judgment  furnished  by  sure  observation.  If 
it  prevents  or  interrupts  action,  or  lays  open  the  obscure  depths 
of  representation  and  action,  it  becomes  a pathological  phenomenon, 
the  expression  of  a state,  which,  by  filling  the  consciousness  with 
the  images  to  which  the  suspicion  is  referable,  frequently  gives  rise 
to  illusions,  and  prepares  or  feeds  the  germ  of  some  forms  of  paranoia 
(of  persecution  and  jealousy).  Paranoic  deliria  are  usually  of 
emotional  origin  (Fere,  Ferrari).  As  a matter  of  fact,  if  the 
weakened  subject,  owing  to  the  altered  process  of  perception,  does 
not  manage  to  form  a clear  judgment  as  to  his  relations  with  his 
environment,  he  begins  to  suspect  the  perfectly  honest  behaviour 
of  his  friend,  he  sees  a threat  in  every  malicious  look,  a trap  in  any 
witticism.  Such  a man  has  already  entered  on  the  path  of 
paranoia. 

But  even  though  they  do  not  reach  this  high  degree  of  develop- 
ment, suspicious  persons  form  that  phalanx  of  fearful  and  undecided 
people  who  find  insuperable  difficulties  in  the  supposed  manoeuvres 
of  their  neighbours,  and  are  always  beholding  their  interests  or  their 
persons  in  danger,  threatened  or  plotted  against. 

Fear  and  suspicion  are  characteristics  of  inferiority  ; they  are 
regressive  manifestations,  and  are  a cause  of  economic  poverty, 


378 


PSYCHIATRY 


because  it  is  not  for  them  that  Fortune  reserves  her  victories.  They 
represent  true  rheostats  in  consciousness,  internal  resistances, 
increasing  in  inverse  ratio  to  the  vigour  and  rapidity  of  action. 

In  some  cases,  however,  the  painful  tone  of  mind  increases  the 
tension  that  is  ready  to  be  discharged  under  the  slightest  stimuli. 
Reaction  is  immediate  and  exaggerated,  and  the  more  so  in  pro- 
portion as  the  threshold  of  pleasure  is  with  difficulty  accessible. 
This  offers  no  contradiction  to  the  general  law  : the  action  is 
simple,  inefficacious,  and  negative,  and  arises  from  the  hyper- 
tension, through  contrast,  of  the  ego  confronted  by  obstacles.  The 
sufferers  are  discontented,  irascible,  and  violent. 

There  are  neurasthenic,  hysteric,  and  epileptic  subjects,  and 
individuals  who  have  suffered  from  shock,  or  an  organic  lesion  of 
the  brain,  who  are  violent  and  choleric  by  reason  of  their  suffering. 
They  laugh  or  cry  on  the  slightest  occasion,  are  subject  to  violent 
impulses  and  fits  of  anger.  These  are  the  commonest  symptoms. 
One  of  the  characteristics  of  epilepsy,  even  when  epileptic  con- 
\ ulsions  are  absent,  is  the  great  irascibility,  the  intense  reaction, 
even  to  slight  stimuli.  In  these  cases  anger  does  not  arise  from 
joy.  The  epileptic  is  not  a joyful  subject  ; at  bottom  he  is  afflicted 
and  fearful.  The  regulative  powers  that  usually  intervene  in 
physiological  reaction  are  wanting,  or  cannot  be  brought  into 
service.  If  these,  which  consist  of  groups  of  ideas  and  other  feelings 
in  contiast,  are  either  absent,  or  are  weak  and  colourless,  and  do 
not  penetrate  into  the  field  of  consciousness,  the  latter  will  be 
governed  only  by  the  representations  aroused  by  the  actual  stimulus, 
the  sole  determinant  of  action.  These  states  are  not  true  and  proper 
maladies,  but  gradations  of  anomalous  character,  more  marked 
in  certain  morbid  conditions,  as  phrenasthenia,  hysteria,  and 
epilepsy. 


Morbid  Gaiety. — It  is  not  always  easy  to  distinguish  some  ^ 
foims  of  morbid  gaiety  from  physiological  mirth.  Every  person  has  i 
experienced  the  inward  joy  that  comes  with  good  news  or  some  happy  | 
event.  It  is  constituted  of  a feeling  of  well-being,  of  strength,  of  * 
one  s own  efficiency,  and  of  the  increased  influence  of  one’s  per- 
sonality in  social  relations.  These  joys  last  for  a relatively  short 
time,  and  leave  a trace  that  becomes  a historical  component  of 
the  personality  ; then  equilibrium  is  re-established  sooner  or  later, 
with  the  formation  of  a new^  habitude.  From  that  state  of  equili- 
biium  the  mind  is  aroused  to  new^  joys  by  new  victories,  or  is  cast 
down  into  the  regions  of  grief  by  defeat  or  fresh  difficulties.  Thus 
life  goes  on,  leaving  behind  an  irregular  diagram  of  ascending  and 
descending  lines,  symbols  of  alternations  of  pleasure  and  pain. 

Some  individuals  are  generally  hilarious,  and  their  psycho- 
organic  habitudes  are  not  easily  disturbed  by  internal  or  external 
inlhiences.  They  are  moderate  in  their  desires,  and  have  an  ex- 


i 


EMOTIONS  AND  SENTIMENTS 


379 


uberant  sense  of  vigour  ; they  are  agreeable  and  expansive,  know 
nothing  of  difficulties,  and  are  the  favourites  in  all  parties  and 
meetings.  Some  of  these  are  actually  possessed  of  vigour,  and  do 
not  feel  resistance  very  much,  winning  for  themselves  a rich  in- 
tellectual equipment,  ever  new  energies  and  resources,  and  easily 
attaining  any  object  that  is  not  out  of  proportion  to  their  powers. 
Others  are  weak  in  spirit,  incapable  of  any  great  synthesis,  anecdotic, 
sometimes  happy  in  their  irony  and  in  contrasts  ; these  excite 
laughter  and  diffuse  hilarity  among  their  friends.  They  also  are 
expansive.  There  are  others,  still  poorer  in  spirit,  vain  and  pompous, 
knowing  nothing  of  the  world,  but  with  a strong  consciousness  of 
themselves,  due  to  exuberant  kinsesthesis.  The  organic  ego  pre- 
ponderates over  the  spiritual  ego,  and  they  assume  a stupidly 
haughty  attitude  in  the  contemplation  of  their  own  persons,  with 
regard  to  which  they  sometimes  have  the  feelings  of  aesthetes. 

As  will  be  seen  from  this  very  brief  sketch,  morbid  gaiety,  like 
morbid  pain,  cannot  always  be  clearly  distinguished  from  the 
physiological  emotions.  From  the  normal  to  the  morbid  the  passage 
is  by  gradations.  We  can  only  affirm  that  mirth  is  morbid  when  it 
is  excessive,  and  is  not  determined  by  sufficient  causes. 

We  distinguish  a calm  gaiety,  which  is  reduced  solely  to  the 
change  of  tone  of  consciousness  and  to  the  well-known  organic 
modifications  characterizing  joy  in  its  various  degrees,  and  joy 
that  is  expressed  in  words,  movements,  laughter,  dancing,  sing- 
ing, etc.  The  general  characteristics  are  a feeling  of  well-being,  of 
power,  of  lightness  in  the  head,  limbs,  and  body.  The  senses  are 
more  acute  ; taste,  smell,  and  sight  become  more  delicate,  and 
facilitate  pleasurable  relations  with  the  external  world.  The 
memory  is  readier  and  happier,  while  associations  are  more  rapid, 
more  extended,  and  more  numerous,  thus  giving  another  source  of 
pleasure.  The  kinsesthesis,  elevated  by  the  feeling  of  well-being, 
the  easy  syntheses,  the  exuberance  of  affective  tensions,  the  slight- 
ness of  resistance  in  the  motor  circuits,  produce  the  expansiveness 
of  the  mirthful  subject,  his  facility  of  speech,  and  rapidity  of 
reaction  under  every  form.  The  power  of  the  ego  that  has  been 
freed  from  internal  resistances  in  consciousness,  such  as  doubts 
and  contrasting  ideas  and  sentiments,  gives  the  illusion  that  ex- 
ternal resistances  are  also  diminished  to  the  same  extent,  and  when 
a man  is  in  this  state,  with  the  circles  of  criticism  closed,  he  gives 
himself  up  to  undertakings  that  may  easily  ruin  him.  One  of 
Hartenberg’s  patients  used  to  say  : ‘ How  pleased  I am  ! I am 
sure  that  a great  fortune  is  going  to  fall  to  me.  I am  in  just  such 
a state  as  if  I had  won  a big  prize  in  a lottery.’ 

In  proportion  as  resistance  and  the  inhibiting  powers  repre- 
sented by  contrasting  ideas  and  feelings  are  defective  or  completely 
wanting,  these  sufferers  generally  turn  out  troublesome  in  varying 
; degrees,  or  even  immoral.  Witticisms,  scoffing,  irony,  insults, 


3«o 


PSYCH  I A TRY 


trivialities,  coquetry,  lasciviousness,  shamelessness,  and  even  ‘ 
violence,  are  sometimes  accompaniments  of  morbid  mirth.  j 

Morbid  joy  is  always  met  with  in  true  mania,  and  in  all  the  i 
maniacal  phases  or  episodes  of  other  maladies,  such  as  circular  J 
insanity,  and  especially  paralytic  dementia.  It  is  a characteristic 
also  of  the  first  stage  of  alcoholic  inebriation,  and  of  all  forms  of 
expansive  paranoia,  while  it  is  met  with  episodically  in  the  hallu- 
cinatory forms,  especially  those  of  religious  or  erotic  content,  in 
hysteria,  epilepsy,  etc. 

We  know  the  anger  that  arises  from  psychic  hyperalgesia,  but 
it  is  easy  to  recognise  the  existence  of  an  anger  proper  to  the  hilarious 
personality,  as  it  is  more  violent,  insomuch  as  the  hilarious  subject, 
with  exuberance  of  all  psycho-somatic  energies,  meets  with  no  | 
resistance  in  the  internal  circuits,  and  will  not  therefore  tolerate 
any  in  the  external  circuits.  He  thus  reacts  excessively  to  opposing  ' 
obstacles,  with  a violence  and  rapidity  proportionate  to  the  psycho- 
kinsesthetic  tensions  occurring  in  the  state  of  ]oy  just  described. 
These  discharges  are  so  much  the  more  violent  and  destructive  | 
because  there  are  open  to  them  the  small  circuits  of  muscular  action,  I 
whilst  the  large  circuits  of  the  intellect  and  of  the  other  inhibiting  ^ 
forces  are  closed  against  them. 

One  form  of  gaiety  is  vanity,  vvdiich  passes  by  degrees  from  the 
physiological  form  manifested  by  a man  and  a woman  on  their  first 
meeting  to  the  pathological  form,  commencing  with  ‘ the  small  ! 
pride  befitting  small  objects  and  small  men  ’ (Mantegazza,  ‘ Physiog- 
nomy and  Mimicry’  i88i).  Usually  it  is  a pretence  of  superioritv 
tending  to  the  undue  display  of  some  good  quality,  or  to  the  undue  ; 
assertion  of  the  value  of  a person  as  a human  being,  on  account  of  ? 
some  one  of  the  qualities  that  predominate  in  his  self-admiration,  i 
So  it  is  with  the  beautiful  and  agreeable  qualities  of  a woman,  who 
will  indulge  in  more  or  less  shameless  flirtation  ; and  so  with  the  ' 
handsome  form,  the  strength,  the  physical  and  intellectual  power  '1 
of  man.  There  is  the  need  of  displaying  something  that  will  make 
us  excel,  something  referable  to  our  own  persons  or  our  own  qualities, 
to  our  power  or  to  notoriety.  There  is  always  simulation,  from  the 
illusion  of  the  imbecile  about  his  own  capacity  to  the  silent  and 
authoritative  pose  of  ignorance  ; from  the  restless  striving  of  the  ; 
scientist  after  notoriety  to  the  admiration  for  which  the  Deputv  ^ 
complacently  lays  himself  out  as  he  conducts  amiable  ladies  to  the 
gallery  of  the  House  to  hear  the  prosaic  speech  that  he  is  going  to 
deliver  ; from  the  artist,  enamoured  of  himself  and  his  boasted 
creation,  to  the  criminal,  who  is  more  interested  in  the  notoriet^’  | 
he  has  earned  by  his  crime  than  in  his  own  condemnation,  \mnity 
IS  veiy  common  in  weak-minded  persons,  in  hysterical  subjects,  in  ^ 


EMOTIONS  AND  SENTIMENTS  381 

the  slighter  forms  of  mania,  and  most  of  all,  as  Lombroso  has  well 
shown,  in  born  criminals. 

In  his  vanity  man  either  pretends  to  beauty,  strength,  capacity, 
and  power  that  he  does  not  possess,  or  he  displays  in  a fair 
and  seducing  light  all  that  he  has.  Pride  is  a true  feeling  of 
superiority,  based  generally  on  some  intellectual  power,  on  strength 
or  capacity.  There  is  a tendency  of  the  social  ego  to  assert  itself, 
and  unlimited  virtuosity  of  expansion.  ‘ The  man  who  has  such  a 
vigorous  consciousness  of  himself,’  says  Ribot,  ‘ resembles  those 
prolific  and  strong-lived  species  of  animals  and  vegetables  that 
would  cover  the  whole  surface  of  the  globe  themselves  alone.’  The 
proud  can  suffer  no  obstacle,  or  even  admit  the  existence  of  obstacles, 
and  when  they  do  meet  with  any  in  their  paths,  their  feeling  of 
superiority  at  once  leads  them  to  take  up  some  aggressive  attitude, 
which  may  be  insolent  or  brutal.  I know  two  forms  of  pride — the 
genuine,  frank,  and  sincere  pride,  that  bears  its  own  proper  physi- 
ognomy, and  the  dissimulated  pride  of  many  men  of  high  rank. 
The  latter  conceal  their  pride  under  the  robes  of  authority  or 
modesty,  whilst  sincere  pride  is  always  displayed,  especially  before 
equals  or  inferiors.  Genuine  pride  walks  with  head  erect,  the  body 
straight  and  slightly  inclined  backwards,  the  chest  distended  and 
projecting,  sure  and  measured  step,  brief  and  imperious  speech  ; 
the  gaze  is  directed  upwards  or  to  the  horizon,  the  lower  lip  pro- 
trudes, and  the  mouth  is  firmly  closed  (Mantegazza).  Pride  is 
a form  of  egoistic  joy,  and  may  be  considered  as  the  fertile  soil  of 
paranoia  of  grandeur.  It  reaches  its  maximum  morbid  develop- 
ment in  that  malady  and  in  the  first  phases  of  certain  forms  of 
progressive  paralysis,  and  that  is  my  only  reason  for  mentioning 
it  here. 

We  have  already  said  that  the  religious  sentiment  is  not  intrinsic 
and  necessary  to  human  consciousness,  but  has  been  evolved,  with 
all  its  factors  of  mysticism,  of  fear  and  of  pleasure,  and  has  become 
by  long  tradition  a mental  habit.  Very  weak  as  it  is  among  us,  it 
makes  upon  me  the  impression  of  a mist  involving  the  consciousness, 
and  clearing  away  in  parts.  For  many  people  it  is  a matter  of 
words  rather  than  of  thoughts  and  sentiments.  In  others,  vanity 
and  fear  hold  the  place  of  faith  and  belief.  Idolatry  among  the 
common  people,  political  interest  among  the  upper  classes  of  society, 
mystic  misoneism,  sceptical  indifference  and  fanaticism — those  are 
the  morbid  forms  assumed  in  most  cases  in  the  absence  of  strong 
ifaith  in  a Supreme  Being.  In  mental  maladies,  therefore,  the 
religious  sentiment  almost  always  disappears,  and  at  most  there 
remains  in  some  cases  the  habit  of  religious  observances.  Many 
who  frequent  the  church,  who  pray  for  hours  at  a time,  and  thread 
their  beads  continuously,  feel  none  of  the  emotions  that  are  the 
basis  of  the  religious  sentiment.  Mysticism  is  a region  of  joy,  in  so 


382 


PSYCHIATRY 


far  as  it  presents  no  difficulties  either  to  thought  or  action,  while  it 
expands  the  ego  in  its  relations  with  the  divinity  and  the  unknown. 
Religious  character  is  often  a mere  varnish  that  insanity  removes, 
just  as  fever  destroys  all  the  cosmetic  embellishments  of  the  simu- 
lator of  youthful  beauty.  Even  when  the  religious  sentiment  is 
more  consistent,  it  vanishes  with  the  malady  ; insanity  very  quickly 
sweeps  away  that  perfume  of  the  soul. 

In  mental  disorders  of  religious  content  we  have  to  do  with 
something  quite  different  from  the  religious  sentiment.  Here  the 
religious  nucleus  of  the  personality  is  substantially  altered,  in  so  far 
as  the  ego  is  either  shipwrecked  among  the  breakers  of  religious 
fear — auto-culpability,  damnation,  perdition,  or  demonomania — 
or  it  is  exalted  to  the  dignity  of  the  divine.  In  the  first  case  we 
come  back  to  the  region  of  morbid  pain  and  fear,  in  the  second  to 
that  of  expansive  paranoia. 

Asceticism  is  a morbid  state  of  mystic  joy,  arising  from  the 
pleasure  that  the  spiritual  ego  takes  in  its  own  expansion  until  it 
comes  into  contact  with  divinity.  It  is  accompanied  by  constantly 
growing  detachment  from  the  ordinary  concerns  of  life,  abandon- 
ment of  personal  duties,  and,  in  the  more  marked  cases,  isolation 
in  caves  or  on  mountains  and  closer  relations  with  the  divinity. 
In  the  legend  of  Buddha,  who  passed  years  on  the  mountains  of 
Ourouvela,  in  the  stories  of  St.  Catherine  of  Siena,  St.  Anthony, 
St.  Francis  of  x\ssisi,  and  many  others,  we  see  that  apostles  of 
religion  passed  periods  of  contemplative  isolation  in  alternation 
with  seasons  of  propaganda  and  apostolate. 

Again,  we  often  meet  with  ecstasy,  the  maximum  of  mental 
concentration,  a form  of  joy.  The  ecstatic  subject  is  completely 
abstracted  from  his  surroundings,  and,  in  the  more  pronounced 
degrees  of  the  malady,  hallucinations  are  frequently  present.  Re- 
ligious ecstasy  is  always  morbid  joy,  and  grows  in  neuropathic  soil, 
either  congenital  or  acquired  ; but  we  must  not  confound  it  with 
concentrated  attention  or  with  the  more  or  less  powerful  cesthetic 
pleasures. 

Tlie  paranoic  believes  that  he  has  become  a Messiah,  that  he 
is  inspired,  and  that  a great  task  has  been  reserved  for  him  in  this 
world.  Here  it  is  not  the  religious  sentiment  that  is  at  work, 
but  the  exalted  and  deranged  personal  ego,  which  utilizes  religious 
belief  in  the  interpretation  of  a new  state  in  concord  with  the 
new  character  of  the  personality. 

The  family  sentiment  has  very  deep  roots  in  the  constitution 
of  the  ego  in  its  three  modes  of  being — the  somatic,  the  spiritual, 
and  the  social. 

From  the  tactile  pleasure  of  suckling  to  the  more  complex 
pleasures  of  alimentation  and  those  that  arise  from  protection  from 
all  dangers  of  infancy,  childhood,  and  youth,  the  family  becomes 


EMOTIONS  AND  SENTIMENTS 


383 


an  inexhaustible  source  of  joy,  through  which  the  personality  is 
evolved  and  assisted  to  overcome  the  difficulties  of  life.  A very 
large  number  of  the  components  of  consciousness  arise  from  this 
source  : the  mother’s  smile  that  invites  infant  hands  to  caress  ; 
the  word  that  offers  comfort  for  the  sufferings  of  childhood  ; the 
equal  participation  in  all  the  vicissitudes  of  life — its  joys,  its  griefs, 
its  common  interests  ; the  imitation  of  one  another  and  the  re- 
ciprocal suggestions  ; the  solidarity  of  that  little  society  where  the 
grief  of  one  is  lightened  by  others  sharing  it,  and  where  joy  is  diffused 
like  a perfume,  and  measured  by  the  number  of  the  family — these 
originate  a very  complex  feeling,  which  in  its  evolution  writes  a 
never-to-be-forgotten  story  in  the  consciousness,  a story  that  is 
comprehensible  only  through  the  representation  of  all  the  members 
of  the  family.  It  is  for  this  reason  that  the  family  sentiment 
offers  strong  resistance  to  any  malady  that  dissolves  the  personality. 
The  pleasure  of  possession  or  of  exercising  power,  reciprocity  of 
defence,  hope,  foresight,  comfort  in  old  age,  are  all  components  of 
the  family  sentiment  that  have  struck  deep  roots,  and  malady  does 
not  destroy  them.  In  many  mental  affections  the  sentiment  is 
found  to  be  weakened,  but  not  extinguished.  The  melancholic 
subject  is  often  preoccupied  about  his  family,  and  would  like  to 
return  to  it.  The  persecuted  paranoic  may  still  have  confidence 
in  the  members  of  his  family,  and  while  he  distrusts  all  others,  in 
the  midst  of  his  own  he  feels  himself  secure  or  in  less  danger.  Many 
patients  in  the  asylum  protest  against  being  taken  from  their  own 
homes,  and  others  are  overcome  with  joy  when  they  are  visited  by 
their  relatives.  Preoccupation  about  the  family  furnishes  material 
to  the  delirium  of  melancholic  subjects.  On  the  other  hand,  love 
for  the  family  is  extinguished  in  paranoia  of  pride  or  religion.  In 
predisposed  persons  it  degenerates  into  jealousy  and,  through 
psychic  contrast,  into  inveterate  hatred,  or  into  impulses  to  injure 
the  person  most  loved. 

We  have  spoken  also  of  love  as  a complex  sentiment,  rising 
from  simple  tactile  pleasure  to  the  highest  emotional  and  intellectual 
expression.  This  development  is  accomplished  by  the  assimila- 
tion of  many  new  components — sensory,  emotional,  and  intel- 
lectual. 

The  evolution  proceeds  from  the  simple  sexual  form  to  the 
sympathetic-sexual  and  to  the  cesthetic-sexual  (which  includes  also 
the  intellectual  components).  On  this  psycho-physiological  out- 
line we  might  construct  a chapter  on  the  psycho-pathology  of  love, 
for  its  pathological  forms  are  many,  and  its  defects  and  perversions 
are  to  be  found  in  multitudes. 

There  are  persons  who  do  not  love,  and  who  never  had  any 
inclination  towards  individuals  of  the  other  sex.  These  are  frigid 
anomalies,  imbeciles  or  idiots.  I have  no  pleasure  in  hearing 


384 


PSYCHIATRY 


a young  man  of  twenty-six  confess  to  me  : ‘ I have  never  approached 
a woman,  and  I feel  no  desire  to  do  so.’ 

Episodically,  sufferers  from  melancholia  feel  no  affection.  They 
are  too  self-centred,  too  preoccupied,  too  suffering,  and  therefore 
have  no  love  for  others.  The  mind  is  polarized  in  a direction 
opposite  to  that  which  consists  with  physiological  love.  In  such 
cases  there  is  at  the  utmost  self-centred  raptus  sexualis,  and  that 
is  not  love.  The  true  sufferer  does  not  love.  There  is  very  little 
love  with  the  persecuted  paranoic  or  with  the  megalomaniac,  the 
latter  of  whom  is  very  egoistic.  On  the  other  hand,  in  states  of 
maniacal  excitement  and  in  some  forms  of  progressive  paralysis,  j 
especially  at  the  beginning,  there  is  often  an  exaltation  of  the 
sentiment  of  love — always  understanding  that  the  sentiment  is 
less  exalted  than  the  instinct.  Usually  there  is  a loss  of  the  senti- 
mental and  intellectual  element,  and  therefore  a commencement  of 
dissolution,  whilst  with  the  extinction  of  the  intellectual  component 
of  love  the  brute  instinct  demands  prompter  satisfaction,  and  is 
less  guarded  in  its  demands. 

There  is  a form  of  exaltation  of  ideal  love  in  hereditary  (con- 
genital) neurasthenic  dreamers,  imbecile  natures,  exalted  paranoics, 
hereditary  subjects,  who  love  according  to  some  romantic  ideal. 
Through  want  of  courage  and  intellectual  resources  these  weaklings 
consume  themselves  in  vain  desire.  They  are  idealists  who  dream  ! 
of  the  love  of  women  with  whom  they  will  never  come  in  contact,  ' 
or  of  unknown  celebrities  and  beauties  ; or  they  are  hysterical 
women,  more  or  less  anaesthetic,  who  are  pleased  only  to  excite  and 
to  torment. 

Evolution  may  be  arrested  at  one  of  its  stages,  and  there  may  be  : 
a morbid  preponderance  of  one  of  the  components  of  love,  either 
the  instinctive  or  the  intellectual ; there  may  also  be  disproportion  ; 
or  want  of  harmony  between  these.  ( 

Idiots  sometimes  show  brutal  manifestations  of  the  sexual  I 
instinct.  They  go  so  far  as  to  attack  a woman  in  the  public  street  > 
or  in  her  own  house — sometimes  their  own  mothers.  In  some  ' 
weak-minded  persons  (phrenasthenics),  more  fully  evolved  than  the  ‘ 
preceding  class,  the  instinct  of  love  is  more  guarded,  and  is  even 
accompanied  by  some  elements  of  sympathy.  In  other  predisposed, 
anomalous,  eccentric,  idealistic,  or  weak-minded  persons  there  is 
a great  preponderance  of  the  intellectual  element.  The  majority  of  ^ 
men  have  the  instinctive  element,  and  are  certainly  defective  in,  1 
although  they  possess  many  of,  the  intellectual  and  moral  com-  J 
ponents  of  love.  J 

After  this  class  of  normal  men  we  place  those  with  excessive  or  I 
extraordinary  sexual  excitability  ; here  we  have  nymphomania,  I 
satyriasis,  and  the  sexual  crises  of  tabes.  I 

Next  come  the  morbid  groups,  the  most  frequent  being  the  I 
idealists  of  love,  or  the  pure  platonics,  who  are  often  impotent.  I 


EMOTIONS  AND  SENTIMENTS  385 

These  may  be  represented  by  a great  pyramid,  on  the  apex  of  which 
are  those  affected  by  paranoia  erotica. 

After  these  we  place  the  perversions,  which  range  from  amor 
synecdochicus  and  masochism  to  the  inversion  of  the  sexual  in- 
stinct ; but  of  these  we  shall  speak  in  a special  chapter. 


The  pathology  of  the  moral  sentiment  becomes  confused  in  the 
vortex  of  social  life.  From  the  normal  condition  to  the  maximum 
degree  of  immorality  we  pass  through  innumerable  shades  and 
gradations. 

The  moral  sentiment  disappears  in  insanity.  I do  not  know 
of  a single  insane  person  who  has  preserved  it  intact,  in  the  sense 
that  he  does  or  does  not  do  beneficent  or  injurious  acts  with  con- 
sciousness of  what  he  is  doing.  Further,  the  emotional  nature  and 
the  facile  reaction  of  the  neurasthenic  subject  show  how  little  he 
can  resist  the  instinctive  demands  of  the  ego  when  he  is  excited. 
The  moral  sentiment  is  a high  point  of  human  evolution  and  a 
complex  mental  product,  and  therefore  it  is  more  certain  than 
almost  any  other  to  be  destroyed  by  a mental  disorder  of  any  sort 
whatsoever.  Destined  to  succeed  the  vanishing  sentiment  of 
religion,  the  moral  sentiment  has  not  yet  struck  deep  roots  in 
human  consciousness,  and  so  it  vacillates.  Egoism  finds  means 
to  enwrap  itself  in  the  most  elegant  vestures  of  the  civilization  of 
the  great  cities  of  both  hemispheres,  and  immorality  in  lordly  robes, 
or  concealed  in  the  flattering  words  of  the  market  and  the  suggestive 
elegance  of  the  club,  in  public  and  administrative  offices,  does 
much  more  harm  than  the  primitive  egoism  of  the  savage. 

The  latter  is  a survival,  and  gives  us  primitive  delinquency — 
theft,  rapine,  homicide  ; the  former  gives  us  civilized  delinquency, 
that  ruins  the  fortune  or  the  reputation  of  a man  or  of  a family,  and 
often  escapes  the  penal  code.  It  is  only  the  arms  of  offence  that 
vary,  according  to  the  times  and  to  the  intellectual  components  of 
which  immorality  astutely  avails  itself  for  its  enterprises  and  its 
victories. 


25 


CHAPTER  VI 


THE  WILL— PHYSIO-PATHOLOGY 

All  psychic  products  result  from  the  transformation,  in  the  nervous 
system,  of  the  energies  of  the  external  world  into  components 
of  the  intellect  and  of  the  emotions,  and  they  have  a tendency  to 
resolve  themselves  into  motion.  The  brain  is  a veritable  trans- 
former of  the  cosmic  energies  into  emotions  and  ideas,  which,  in 
their  turn,  are  reduced  to  motion.  The  emotions,  on  the  one  hand, 
are  reflected  upon  the  thalamus,  and  on  the  inferior  centres  of  the 
accompanying  organic  phenomena,  perhaps  also  upon  the  som- 
cesthetic  zone,  while,  on  the  other  hand,  they  give  colour  to  the  ideas 
and  increase  their  motor  potential.  Ideas  have  always  a tendency 
towards  expression  in  speech  and  in  action,  and  this  will  be  the  more 
complex  the  greater  the  number  of  the  constituent  elements  of  the 
intellectual  syntheses.  But  action,  of  whatever  nature  it  be,  is 
more  ready  and  efficacious  with  a quid  and  with  a quale  of  emotion, 
constituting  what  we  call  interest.  When  these  two  components 
associated  with  the  intellectual  syntheses  are  absent  or  too  feeble, 
action  fails  or  remains  in  consciousness  as  a simple  motor  tendency, 
rudimentary  and  inefficacious. 

The  quid  of  emotion  associated  with  ideas  must  not  exceed  a 
certain  measure  ; and  the  quale  of  emotion  determines  the  form  and 
direction  of  the  action.  When  the  emotion  exceeds  a determined 
degree  of  intensity,  it  tends  to  be  resolved  into  inferior  reflexes,  with 
a prevalence  of  somatic  phenomena  and  a loss  in  value  of  the 
intellectual  syntheses.  If,  on  the  other  hand,  the  quale  of  emotion 
is  characteristic  of  the  inferior  types  of  emotivity,  in  this  case  also 
action  is  resolved  in  the  small  reflex  circuits,  with  insufficient  direc- 
tive influence  of  the  intellectual  syntheses.  High  mental  evolution 
presupposes  the  predominance  of  emotions  of  a high  order  which 
liave  assimilated  the  greatest  possible  number  of  intellectual  com- 
])onents  and  of  altruistic  emotions,  these  last  being,  under  like  con- 
ditions of  intellectual  development,  the  surest  guarantee  for  the 
determination  of  complicated  and  efficacious  action. 

We  may  therefore  conclude  that  human  actions  are  only  reflexes 

386 


THE  V/ ILL— PHYSIO-PATHOLOGY 


387 


go^•erned  by  the  same  laws  as  govern  the  spinal  reflexes.  These 
latter  beconie  progressively  complex  in  proportion  to  the  increase 
m the  number  of  nervous  elements  contributing  to  them.  It  is 
natural  that  the  spinal  reflexes  should  be  simpler  than  those  having 
their  centres  in  the  optic  lobes,  that  the  latter  should  be  simpler 
than  the  thalamic  reflexes,  and  should  reach  their  maximum  degree 
ot  complexity  and  variability  in  the  cerebral  mantle. 

If  we  could  imagine  what  a large  sum  of  stimuli  is  included  in 
he  investigation  of  a problem  of  microscopy,  as,  for  example,  the 
structure  of  the  nerve-cell,  in  comparison  with  the  sum  of  stimuli 
acting  upon  a hungry  man  who  sees  a piece  of  bread-and  what  a 
difference  tyre  exists  between  the  latter  and  the  contact  with  the 
yle  ophe  foot  that  determines  the  plantar  reflex-we  should,  per- 
haps, find  the  reason  oi  the  simplicity  of  the  last  in  comparison  with 
the  TOmphcation  of  the  second,  and  the  complexity  of  the  series  of 
reactions  m pe  first,  which  demands  many  years  of  labour,  pro- 
^mtliTsef  ^ number  and  the  comyexity  of  the  intellecLal 

’I  reflyes  of  the  intellectual  and  emotional  syntheses— 
at  IS  to  say  the  reflexes  in  the  mantle— that  we  call  voluntary, 
hyvill  IS  nothing  more  than  the  conscious  resolution  of  the  motor 
yndencies  of  the  intellectual-emotional  syntheses,  and  we  may 
figure  It  to  yrselves  as  a conscious  motor  potential  tending  to  dis- 
harge  itself  through  circuits  of  various  orders,  from  the  lowest 
which  much  resemble  the  inferior  and  instinctive  reflexes,  to  the 
humS’ty'^^*'^^  represented  in  the  actions  of  the  heroes  of 

voluntary  attention.  In 
the  ycond  chapter  we  have  seen  that  sensory  stimuli  give  rise  to 
a reflex  of  the  mantle  that  goes  under  the  name  of  reflex,  passive 
or  sensory  attention.  This  may  depend  upon  the  fact  that  the 

ty  intensity  of  the  stimulus,  coinciding  with  a slight  intensification 

tte^LeTsffvTf  's  strong  in  comparison  with- 

e intensity  of  the  stimulus,  which  consequently  gives  rise  to  a 

relatively  great  movement,  the  attention  is  termed  voluntary  It 
y dear  thy  the  intensification  of  the  sensation  can  take  place  only 
roup  the  camng  up  of  associated  images  evoked  by  fte  slight 
stimulus,  and  this  leads  us  to  conclude  that,  under  equafconditioL 

b?ef  ry  proportion  to  the  mental  content  that  can 

be  evoked  in  a given  unit  of  time  under  the  influence  of  external 
or  internal  stimuli  ; and  also  to  the  resistance  that  it  meets  with 

owing  y non-habituation  of  the  paths  of  association  and  of  those 
throuy  which  It  is  discharged. 

This  last  form  of  attention  sometimes  presents  another  char 
refer  when  it  meets  with  strong  resistance  to  its  exercise  and 
recomes  a particular  condition  of  consciousness  termed  ^ 

25—2 


PSYCHIATRY 


388 


In  the  sphere  of  attention,  effort  consists  in  the  maximum  degree  of 
concentration  of  the  power  of  attention,  as  if  to  close  all  the  col- 
lateral circuits  and  to  open  to  the  discharge  only  those  channels 
that  will  most  easily  and  surely  lead  to  the  object  of  attention.  In 
general,  effort  represents  the  maximum  concentration  of  the  motor 
potential,  proportioned  to  maximum  resistances.  ^Thus  we  find, 
even  in  common  parlance,  the  phrase  ‘ effort  of  will.’ 

One  of  the  most  important  links  of  volitional  reflex  is  destre, 
of  which  we  have  already  made  some  mention  in  the  preceding 
chapter  on  Emotion.  Here  we  add  that  desire,  adopting  the  phrase- 
ology of  Mercier,  is  will  in  posse,  and  arises  from  the  increa,sed  motor 
and  emotional  potential  of  a determined  nervous  mechanism,  which 
fills  the  consciousness  until  the  discharge  has  been  effected,  or  until 
it  is  substituted  by  another  mechanism,  itself  also  overcharged  with 
high  emotional  and  motor  tension.  As  the  charge  on  such 
mechanism  increases,  desire  becomes  more  intense,  and  reaches  the 
mechanism  of  will,  into  which  that  of  desire  discharges  its  tensions. 
Desire,  and  therefore  will,  are  always  tending  towards  movements 
that  will  procure  pleasure  and  integration,  and  remove  pain  or 
disintegration. 

Two  orders  of  voluntary  actions  are  to  be  distinguished  : those 
determined  by  instinct  and  those  determined  by  reason.  Some- 
times both  mechanisms  become  overcharged  with  motor  tension 
in  conflict  with  consciousness.  Instinct  discharges  itself  along 
shorter  circuits,  and  the  moment  preceding  the  discharge  we  call 
determination.  The  intervention  of  the  mechanism  of  reason  char-  : 
acterizes  what  we  term  free  choice. 

The  problem  of  determination  is  extremely  important,  because 
choice  is  sometimes  in  conflict  with  determination,  whose  power, 
in  that  relation,  depends  upon  the  degree  of  organization  of  the. 
mechanism  of  the  corresponding  activity,  and  upon  the  motor  ■ 
potential  of  such  organized  mechanism. 

Choice  always  coincides  with  a conflict  in  consciousness  between 
different  motor  potentials  in  relation  with  ideative  or  emotional 
mechanisms,  which  in  their  turn  surcharge  motor  mechanisms.  In 
choice  the  power  of  attention  also  increases,  and  when  it  works 
upon  the  memory  and  the  imagination  it  raises  the  efficiency  of  the 
separate  ideative  mechanisms  to  a high  potential.  Thought, 
imagination,  and  attention  are  coefficients  of  will  with  choice.  The 
resolution  of  attention  will  come  from  that  mechanism  in  which 
the  potential  has  been  raised  highest  by  the  interest  excited  by  the 
emotion,  in  connection  with  the  judgment  of  advantage  and  utility 
to  the  personality.  Here  another  factor,  also  based  upon  atten- 
tion and  imagination,  comes  into  pla}^ — that  is,  inhibition,  lepie- 
sented  by  other  ideative  and  motor  mechanisms  which  have  been 
called  into  activity  for  the  purpose  of  removing  what  is  less  usefu 
or  even  dangerous  to  the  personality.  On  the  chess-board  0 


THE  WILL— PH YSIO-PA  THOLOG Y 


3S9 


ideative  and  emotional  mechanisms,  to  which  choice  and  the  act 
of  deliberation  are  referable,  the  game  that  is  played’  involves  the 
fate  of  the  personality.  That  one  of  the  mechanisms  which  has 
reached  the  highest  degree  of  intensification  of  thought  discharges 
its  tension.  Intensification  implies  judgment  and  attention.  The 
motive  is  furnished  by  interest,  and  therefore  by  the  desire  to  secure 
what  is  pleasing  and  beneficial,  and  to  remove  what  is  not  pleasing, 
hurtful,  or  less  useful,  or  by  the  desire  to  satisfy  a want  belonging 
to  the  category  of  instincts  or  quasi  instincts. 

It  is  to  be  noted  that  both  in  determination  and  in  choice  the 
greater  probabilities  favour  the  working  of  the  mechanism  most 
accessible  to  movements,  which  implies  that  such  mechanism  has 
already  been  at  work,  and  therefore  should  offer  less  resistance  to 
the  psycho-motor  tension.  It  is  in  this  way  that  habits  of  conduct 
are  formed,  and  thus  we  explain  the  difficulty  of  new  psycho-motor 
organizations,  which  always  fall  to  the  strongest  organisms  ; whilst 
the  difficulty  of  breaking  off  habits  is  the  reason  of  individual  and 
collective  misoneism. 

The  question  of  free-will  is  therefore  reduced  to  all  the  factors 
of  will  with  choice  : 

1.  Number  and  value  of  intellectual  syntheses. 

2.  Degree  and  value  of  emotive  syntheses. 

3.  Contrasting  emotional-intellectual  syntheses. 

4.  Degree  of  permeability  of  the  motor  paths  and  aptitude  for 
the  formation  of  new  motor  mechanisms. 

5.  Degree  of  the  psycho-somatic  sensibility  of  the  ego,  which 
has  a tendency  to  follow  habitual  paths. 

Voluntary  movement  finally  requires  the  representation  of  the 
image  of  the  actual  movement,  without  which  it  could  not  be  com- 
pleted ; but,  the  analysis  of  this  factor  belonging  rather  to  physi- 
ology and  nervous  semeiology,  I limit  myself  here  solely  to  the 
mention  of  it. 

The  pathology  of  will  is  perhaps  the  most  important  chapter 
of  mental  pathology,  and  for  that  very  reason  it  is  impossible  for 
us  to  make  a complete  analysis  of  it  here.  When  we  consider  that 
action  is  the  last  fact  in  a series  of  others,  from  which  it  necessarily 
arises  and  emanates  as  the  resultant  of  converging  and  diverging 
forces,  it  is  quite  clear  that  voluntary  action  must  partake  of  what- 
ever defect  or  irregularity  of  function  there  may  be  in  the  various 
mechanisms  from  which  it  has  its  origin.  Perceptive  power,  the 
powers  of  memory,  attention,  and  association,  the  innate  capacity 
for  the  formation  of  active  intellectual  syntheses,  the  degree  of 
evolution  of  the  emotion,  all  concur  in  forming  the  character  of 
voluntary  determination,  and  this,  in  its  turn,  gives  character  to 
the  personality.  Defective  perception  generates  error  of  move- 
ment, which  destroys  the  effect,  just  as  hallucination  furnishes  the 
material  of  a judgment  and  of  an  intellectual  and  emotional  syn- 


39« 


PSYCHIATRy 


thesis  which  in  its  turn  gives  rise  to  an  action  opposed  to  the  funda- 
mental law  of  the  interest  in  conservation  and  development  of  the 
psycho-physical  personality,  which  is  always  co-ordinated  with 
reality.  The  sufferer  from  religious  hallucination,  who  pursues 
theistic  phantasms  and  preaches  a reformation,  or  the  erotic  idealist 
whose  consciousness  is  so  filled  with  reflections  upon  the  smile  of  a 
lady  that  he  will  run  after  her  in  the  street,  furnish  examples  of 
will  with  choice  determined  by  anomalies  of  the  formative  process 
of  judgment,  based  upon  false  sensory  products.  The  persecuted 
subject  who  pesters  the  authorities  for  protection  of  his  person  and 
his  interests,  threatened  by  supposed  enemies,  or  the  melancholiac 
who  commits  suicide,  perform  acts  of  will  with  choice  that  are 
logical,  because  the  direction  of  their  choice  is  determined  by  in- 
tellectual and  emotional  mech^isms  that  have  been  profoundly 
altered.  If  in  the  mind  of  the  melancholic  subject  there  no  longer 
vibrates  even  the  faintest  hope  of  pleasure,  he  thereby  loses  any 
reason  for  living,  and  there  is  only  one  way  opened  to  voluntary 
determination — viz.,  that  of  suicide,  which  is  the  logical  expression 
of  the  negation  of  personality : all  the  other  channels  are  ob- 
structed. 

The  famished  boy  who,  under  the  impulse  of  the  instinct  of 
self-preservation  and  of  affection  for  his  sister,  steals  a loaf  of  bread 
to  procure  the  unspeakable  joy  of  satisfying  the  hunger  that  has 
tormented  him  for  hours,  and  of  sharing  this  joy  with  his  beloved 
sister  (Zola,  Le  Travail),  performs  an  action  that  has  all  the  char- 
acteristics of  a choice  that  is  logical  and  inevitable,  just  as  homicide, 
in  the  case  of  a man  whose  consciousness  is  filled  with  the 
homicidal  idea,  against  which  he  has  vainly  used  every  effort  to 
protect  himself  (homicidal  obsession),  is  unavoidable.  In  the  boy 
no  other  ciixuits  have  been  formed  through  which  the  tendons 
of  will  and  the  satisfaction  of  the  instinct  of  hunger  may  be  dis- 
charged. In  the  man  obsessed  by  an  idea,  the  circuits  already  formed 
in  connection  with  numerous  intellectual  and  emotional  syntheses 
are  obstructed,  because  the  consciousness,  invaded  by  the  besetting 
idea,  is  closed  to  all  these  intellectual  and  emotive  S5mtheses.  Even 
when  they  penetrate  to  it,  their  value  is  insignificant  in  comparison 
with  the  high  motor  potential  of  the  synthesis  that  rules  as  mistress 
in  his  consciousness.  The  conduct  of  the  helpless  or  ridiculous 
imbecile,  like  that  of  the  idiot  who  amuses  himself  by  spreading 
fire,  is  the  equivalent  of  the  doings  of  the  criminal  who  lacks  the 
higher  emotional  syntheses  and  the  aptitude  for  the  formation  of 
new  circuits  that  will  facilitate  action  less  instinctive  and  more 
beneficial  to  himself  than  theft  or  robbery. 

Where  the  intellectual  and  the  emotional  syntheses  are  wanting, 
or  are  not  sufficiently  active  to  charge  the  motor  mechanisms  with 
the  potential  necessary  for  action,  there  we  have  imitation  or 


THE  WILL— PHYSIO-PATHOLOGY 


391 


suggestion,  both  of  these  in  weak  natures — neurasthenics,  phren- 
asthenics,  hysterical  subjects,  and  demented  persons. 

Pain,  which  is  paralyzing,  obstructs  all  the  motor  circuits, 
because  it  forbids  the  penetration  of  the  intellectual  and  emotional 
syntheses  into  consciousness,  and  we  have  ahoulia,  the  lack  of  will. 
If  the  syntheses  are  dissociated,  as  in  mental  confusion  or  in  amentia, 
there  is  also  aboulia,  because  all  the  ideo-motor  mechanisms  are 
broken,  and  there  remain  only  the  instinctive  mechanisms,  or  some 
of  these,  or  whatever  new  formation  connects  itself  with  a hallucina- 
tion or  an  ideo-motor  residuum  of  the  old  personality.  Here,  too, 
there  is  aboulia,  due  to  another  cause. 

If  the  ideative  synthesis  lack  the  colouring  that  should  come 
to  it  from  the  numerous  nutritive  channels  of  the  unconscious, 
because  the  laboratories  of  the  latter  are  giving  a scanty  product, 
as  in  neurasthenic  subjects,  the  potential  that  determines  the  action 
is  weak,  and  the  action  remains  in  consciousness  as  a desire  that 
slowly  vanishes — it  is  another  form  of  aboulia  ; and  if  in  hesitating 
persons,  who  are  also  neurasthenic,  none  of  the  various  ideo-motor 
mechanisms  in  contrast  reaches  the  degree  of  tension  necessary 
for  discharge,  the  action  remains  latent,  and  in  this  result  we  find 
a defect  or  an  anomaly  of  will. 

If,  on  the  other  hand,  the  intellectual  syntheses  are  highly 
coloured,  as  in  morbid  gaiety,  mania,  and  progressive  paralysis, 
and  if  these  syntheses  succeed  one  another  rapidly  in  their  passage 
through  consciousness,  being  continually  formed  and  resolved,  the 
will  reflects  on  the  action  of  these  sufferers  a volubility  in  propor- 
tion to  the  rapidity  of  the  intellectual  formations,  and  this  explains 
their  inconsistency  and  their  inefficacy. 

The  obstinacy  of  will  displayed  by  some  persons  arises  most 
frequently  from  insufficient  formation  and  representation  of  other 
intellectual  syntheses  and  motor  mechanisms  than  those  that  have 
won  a favoured  position  in  consciousness  and  are  therefore  pre- 
dominant. The  impulsiveness  of  the  epileptic  depends  upon  the 
extraordinary  charge  of  one  intellectual  - emotional  formation — 
generally  of  low  type  and  already  preformed.  The  discharge  takes 
place  under  the  slightest  external  stimuli,  and  may  appear  to  be 
voluntary. 

If  the  motor  mechanisms  of  a low  type  tend  to  autonomy, 
breaking  off  relations  with  the  intellectual  syntheses  that  first 
determined  them,  we  have  tics,  automatism,  and  compulsions — all 
forms  of  aboulia. 

In  general,  the  will  acts  through  an  extraordinarily  large  series 
of  circuits,  the  extent  of  which  varies  very  much  in  different  indi- 
viduals, according  to  the  degree  of  evolution  and  the  transformations 
induced  by  mental  disorder.  These  circuits  run  from  the  smallest, 
for  the  satisfaction  of  individual  instincts,  to  the  largest,  intended 


392 


PSYCHIATRY 


for  the  exclusive  use  of  the  social  ego.  The  former  are  the  oldest, 
the  latter  somewhat  recent.  The  one  series  has  its  culmination  in 
the  past,  the  other  in  the  future  ; but  the  will  has  always  essentially 
the  same  characteristics,  and  we  must  seek  its  anomalies  in  the 
mental  organization  and  in  the  influence  that  the  various  components 
of  which  the  mind  is  constituted  exercise  in  the  formation  of  the 
motor  mechanisms.  ^ 

To  speak  of  the  various  forms  of  pathological  will  would  be  to 
take  the  reader  over  almost  the  whole  course  of  insanity  in  the 
individual  and  in  the  social  world,  and  the  task  would  be  a useless 
one.  After  what  we  have  said,  each  student  will  easily  form  the 
synthesis  of  the  pathology  of  will  when  he  has  read  the  third  part 
of  this  work. 


CHAPTER  VII 


CONSCIOUSNESS 

Consciousness  is  a representative  or  reactive  perceptive  moment 
connected  with  the  past  experience  of  the  personality.  It  varies 
in  its  continuity  just  as  the  percepts  and  mental  representations, 
as  well  as  the  emotions  constituting  its  domain,  vary.  It  is  a small 
part  of  the  somatic  and  intellectual  being  revealed  to  itself  at  a focus, 
upon  which  the  mechanism  of  illumination  is  kept  active  by  all  the 
obscure  and  deep-seated  laboratories  of  the  memory  : it  is  the  ego 
differentiated  from  the  world  ; all  the  more  so  the  more  extensive 
the  knowledge,  and  the  greater  the  number  of  psychic  syntheses 
formed  by  it.  We  are  thus  entitled  to  say  that  consciousness  is 
co-extensive  with  notions  and  reactions. 

Psychologists,  like  James  and  Mercier,  speak  of  a somatic  ego, 
of  a spiritual  ego  as  distinct  from  the  foregoing,  and  of  a social  ego 
that  comprehends  the  thoughts,  the  emotions,  and  the  actions  of 
man  in  relation  to  his  social  environment.  These  are  scholastic 
distinctions,  to  be  accepted  only  because  of  their  utility  in  enabling 
us  to  understand  the  various  aspects  of  the  ego.  For  example,  I 
cannot  represent  to  myself  my  somatic  ego,  unless  as  associated 
with  the  emotional  and  intellectual  phenomena,  even  with  the  most 
elementary  of  these,  such  as  those  of  space  and  of  relations  in 
space. 

The  somatic  ego,  that  which  we  suppose  to  be  constituted  by 
the  syntheses  of  all  the  obscure  nerve-waves  that  reach  the  brain 
from  all  points  of  the  body,  cannot  be  represented  otherwise  than 
with  the  assimilation  of  intellectual  products  resulting  from  the 
contact  of  the  organism  with  external  agents.  The  action  of  these 
latter  gives  rise  to  an  extremely  large  and  varied  series  of  modi- 
fications of  the  organism,  and,  at  the  same  time,  to  another 
equally  varied  series  of  percepts  and  their  compounds,  whence  the 
mind  is  formed.  The  spiritual  ego,  the  result  of  these  last,  is  the 
arborization  of  the  first  grafts  from  Nature  into  the  senso-somatic 
trunk,  their  buds  being  nourished  by  contact  with  the  environment 
and  with  the  sap  of  the  trunk,  whilst  at  the  same  time  they  send 

393 


394 


PSYCHIATRY 


into  the  deepest  subterranean  reservoirs  many  products  of  their  j 
transformation.  It  is  in  this  way  that  there  is  established  the  ! 
continuity  of  the  somatic  ego  with  the  inseparable  spiritual  ego,  ' 
each  of  the  two  becoming  an  essential  condition  of  consciousness.  ! 
All  percepts,  associative  products,  syntheses,  new  or  old  intellectual  * 
constructions,  the  ruins  of  old  edifices,  all  the  emotional  experiences  ' 
and  forms  of  reaction,  from  the  simplest  reflexes  that  are  hardly 
noticeable  to  the  instinctive  and  the  multiform  actions  operating 
on  the  social  environment,  concur  in  one  single  synthesis,  which  is 
the  ego.  It  is  illuminated  only  in  some  of  its  components,  but  it  , 
is  to  be  recognised,  in  its  historic  entirety  and  in  its  synthesis  as  j 
a whole,  always  differentiated  from  that  of  other  beings,  the  more 
entirely  so  the  fuller  its  knowledge  of  its  environment  and  the 
greater  the  number  of  its  own  motor  experiments  upon  the  world. 

The  somatic  consciousness,  therefore,  is  not  differentiated  and 
representable  in  its  ensemble  and  in  its  parts  except  through  the 
relations  of  the  body  with  the  external  world — that  is  to  say,  through 
sensations  acting  outwards.  All  the  perceptions  concur  not  only  in 
the  formation  of  the  intellectual  consciousness,  which  is  formed 
essentially  of  percepts,  of  their  syntheses,  and  of  their  varying 
combinations,  but  also  in  the  formation  of  the  somatic  consciousness, 
in  so  far  as  every  perception  contains  the  somatic  element  that  is 
furnished  by  the  contact  of  the  body  with  external  agents,  of  which 
the  expression  is  found  in  percepts.  Just  as  visual,  aural,  tactile  and 
other  forms  of  consciousness  are  formed  from  the  respective  intel- 
lectual components,  and  the  innumerable  syntheses  from  the  pro- 
ducts of  the  sensory  areas,  the  great  trunk  of  the  somatic  conscious- 
ness is  nourished  by  the  somatic  elements,  and  in  its  turn  this  con- 
sciousness will  maintain  very  intimate  relations  with  that  portion 
of  the  intellectual  formation  most  fully  nourished  and  most  easily 
representable.  Thus  it  is  that  we  have  the  prevalence  of  a certain 
different  tone  in  visual,  aural,  and  motor  subjects. 

Besides  the  intrinsic  modification  of  separate  parts  of  the  body 
by  the  external  agents  that  furnish  formative  elements  of  the 
somatic  consciousness,  we  must  mention  all  the  emotional  experi- 
ences of  pleasure  and  pain  accompanying  sensations,  which  are 
reverberated,  as  we  have  already  explained  in  the  preceding  chapter, 
partly  into  the  field  of  intellect  and  partly  into  the  field  of  emotion  ; 
for  it  is  well  to  remember  that  the  body  participates  intrinsically, 
with  the  somatic  phenomena,  in  the  emotion  and  in  the  advantage 
that  the  personality  derives  from  external  agents,  or  in  the  hurt  to 
which  it  is  subjected  by  them. 

In  the  formation  of  the  somatic  consciousness  there  is  a strong 
concurrence  of  motor  reactions,  from  the  simplest  reflexes  to  the 
most  complex  actions  in  the  social  relations  of  each  individual. 
Every  voluntary  movement,  besides  the  psychic  mechanism  of 
which  we  spoke  briefly  in  the  preceding  chapter,  contains  all  the 


CONSCIOUSNESS 


395 


somatic  elements — tactile,  muscular,  articular,  and  the  sense  of 
innervation — that  furnish  the  image  of  the  movement  to  be  made, 
and  that  are  reinforced  by  the  images  of*  already  completed  move- 
ments. Motor  experiences,  especially  those  involving  effort,  are 
the  largest  contributors  of  elements  to  the  somatic  consciousness, 
which  is  fused  with  the  intellectual,  the  emotional,  and  the  volun- 
tary consciousness,  and  can  hardly  be  represented.  When  we 
perceive,  think,  are  moved,  or  act,  we  represent  to  ourselves  the 
object  of  the  perception,  the  thought,  the  emotion,  or  the  end  to 
which  our  will  and  action  are  directed.  Except  in  strong  emotions, 
the  somatic  consciousness  almost  always  remains  behind  the  scenes 
of  our  psychic  life.  Exposed  to  view,  however,  is  the  perpetual 
movem.ent  of  what  we  know,  what  we  think,  what  moves  us,  what 
we  desire,  all  those  other  things  to  which  we  aspire,  and  which  we 
wish  to  procure  or  remove  from  us.  Under  the  various  circum- 
stances of  life  the  scenes  succeed  one  another  with  contents  at  one 
time  more  intellectual,  at  another  more  determinative.  Conscious- 
ness changes  as  thoughts,  emotions,  and  aspirations  change.  The 
distinction  of  a somatic,  a spiritual,  and  a social  ego,  and  the  sub- 
distinction of  a religious  ego,  an  sesthetic  ego,  etc.,  are  therefore 
more  than  scholastic.  It  is  the  necessity  for  analysis  that  induces 
us  to  distinguish  forms  of  personality  that  cannot  be  realized.  The 
psychologist  must  penetrate  into  the  inmiost  structure  of  the  ego, 
because  consciousness  is  a synthesis  of  all  the  components  of  the 
mind,  and  changes  with  the  movement  of  these  components  as  they 
pass  the  illuminated  point.  It  is  the  frequency  with  which  certain 
preferred  components  return  to  the  illuminated  point  that  gives 
the  personality  its  particular  tone  or  character. 

If  a man  has  the  conviction  of  the  existence  of  God,  although  he 
has  no  personal  experience  of  his  relations  with  Divinity  (and  therein 
lies  the  essence  of  faith) ; if  he  submits  to  all  that  he  believes  to  be 
the  will  of  this  Supreme  Being,  obeys  all  His  commandments,  and 
in  all  circumstances  and  vicissitudes  of  life  derives  the  rule  of  his 
conduct  from  that  belief,  we  say  that  that  is  a religious  conscious- 
ness, be  it  moral  or  not,  provided  it  arises  from  the  relation  of  the 
ego  with  the  Divinity  believed  in. 

We  may  speak  of  an  aesthetic  consciousness  if  there  be  penetra- 
tion of  the  ego  into  the  sense  of  things,  with  harmony  of  forms  and 
colours  and  with  rhythm  and  harmony  of  sounds.  In  intensifica- 
tion of  the  aesthetic  consciousness  there  is  detachment  from  every- 
thing else,  in  order  that  there  may  be  complete  absorption  in  the 
object  of  beauty.  So,  also,  may  we  speak  of  the  moral  consciousness, 
religious  or  not,  of  the  man  who  acts  rightly,  and  whose  social 
relations  are  always  for  the  benefit  of  his  fellows.  These  syntheses, 
however,  are  the  effects  of  the  prevalence  of  some  of  the  contents  of 
consciousness  over  others,  and  of  survivals  of  the  same  in  the  con- 
tinuous movement  of  the  psychic  components  of  the  personality. 


396 


PSYCHIATRY 


We  might  also  consider  that  there  is  a social  consciousness,  not 
in  the  sense  of  religion  or  ethics,  but  in  the  sense  of  human  groups 
constituted  for  dehnite  purposes.  Commercial  and  industrial  : 
societies,  political  associations  and  groups,  the  more  extended  | 
associations,  such  as  those  of  students,  the  army,  the  magistracy,  I 
legislative  bodies,  etc.,  are  social  groups  in  which  we  notice  a certain  ^ 
uniformity  of  consciousness  which  emanates  from  the  object  for 
which  the  social  group  has  been  constituted,  and  which,  in  its 
turn,  determines  a certain  affinity  of  conduct  that  creates  similar 
habitudes. 

To  this  factor  of  the  social  consciousness  is  to  be  added  that  | 
of  imitation,  which  arises  from  the  frequent  contact  of  men  asso- 
ciated for  a common  end  under  almost  equal  conditions.  Sometimes 
what  appears  to  be  imitation  is  an  imposed  rule,  as  in  the  army, 
and  for  this  reason  we  cannot  wholly  adopt  the  concept  of  Tarde, 
who  defines  society  as  a circle  of  imitation.  At  the  utmost,  that 
might  be  said  of  excited  crowds.  Neither  could  I adopt  the  idea 
of  Le  Bon,  who  thinks  that  the  crowd  is  the  only  social  group,  for 
this  reason,  conspicuous  among  others,  that  emotivity  and  im- 
pulsiveness prevail  in  a crowd,  and  in  its  components  there  is  a 
form  of  social  consciousness  rather  imitative  and  obscure  ; whilst  i 
for  the  social  groups  of  which  I have  already  spoken  there  exist  ” 
fixed  common  ends,  far-off  aspirations,  and  great  intellectual 
labour,  ordinarily  with  the  development  of  action  beneficial  either  ;| 
to  the  particular  group,  or,  more  commonly,  to  a wider  section 
of  human  interests.  In  the  social  consciousness,  therefore,  it  is 
not  imitativeness  that  prevails,  but  community  of  ideas  and  of  !| 
sentiments  ; and  if  the  crowd  is  a servile  herd  (Le  Bon),  it  has  only  ' 
one  form  of  social  consciousness,  which  varies  according  to  the  ends  ' 
of  life,  just  as  there  is  variation  of  the  relations  of  the  ego  with  the  ;| 
other  egos  of  the  innumerable  social  groups.  In  the  social  con-  \ 
sciousness,  which  consists  in  the  physiological  fusion,  in  each  ego  of  j 
the  group,  of  the  ideas,  the  aspirations,  and  the  conduct  of  other  ] 
egos,  we  must  take  account  of  the  element  of  opposition  which  comes  i 
from  those  individuals  who  have  the  strongest  conception  of  ideas,  ^ 
means,  and  ends  different  from  those  of  the  group,  who  do  not  yield 
to  the  power  of  imitation,  who  break  up  the  habitudes  of  the  group, 
and  direct  its  action  into  other  channels.  They  open  up  new 
paths  of  conduct  and  become  centres  of  the  imitative  actions  of 
the  whole  group,  or  they  separate  from  it  and  constitute  a fresh 
group.  The  element  of  opposition  in  the  social  consciousness  of  a 
group  is  often  the  germ  of  new  factors  of  social  consciousness,  and 
in  tlieir  development  we  have  one  of  the  causes  of  progress. 

Tlie  distinctions  of  somatic  ego,  intellectual  ego,  and  social  ego, 
under  whatever  form  we  may  consider  them,  are  only  aspects  under 
which  we  may  examine  consciousness.  In  every  case  we  must  divide 
consciousness  into  two  parts,  the  illuminated  and  the  obscure. 


CONSCIOUSNESS 


397 


The  illuminated  part  is  the  so-called  visual  field  of  consciousness. 
We  know  that  it  can  contain  only  a small  number  of  representations, 
and  therefore  it  is  easy  to  conceive  how,  in  any  unit  of  time,  the 
great  mass  of  notions  and  of  emotive-motor  experiences  of  the 
personality  must  rest  in  a much  larger  field  which  is  not  illuminated. 
The  illuminated  and  the  non-illuminated  field  together  constitute 
an  organic  whole,  the  latter  field  furnishing  to  the  former  all 
that  has  been  preformed  or  is  actually  forming  in  the  most 
diverse  combinations,  as  we  have  said  in  one  of  the  foregoing 
chapters. 

The  illuminated  field  presents  the  conditions  best  adapted  for 
maintaining  the  contact  of  the  ego  with  the  external  world,  and  for 
utilizing,  through  these  relations,  the  whole  patrimony  of  the  psychic 
personality  conserved  in  the  non-illuminated  part — that  is  to  say, 
in  the  uneonscious.  In  other  words,  ‘ the  unconscious  ’ supplies  to 
consciousness  all  the  data  of  the  individual  history  essential  for 
useful  adaptations  of  the  personality  to  its  environment.  The 
illuminated  field  is  also  a place  of  preparation  of  instantaneous 
syntheses  and  of  new  reactions,  but  this  work  of  synthesis  is  not 
unknown  to  the  more  profound  and  obscure  departments  of  the 
unconscious.  Normal  relations  with  the  external  world,  attained 
through  the  illuminated  field  across  which  all  objects  in  the  world 
pass  for  their  spiritualization,  involve  the  putting  of  the  ego  into 
relation  with  reality,  and  actual  reality  into  relation  with  other  past 
realities  constituting  the  experience  of  the  ego  at  successive  times. 
To  the  illuminated  field  invariably  belongs  the  control  over  the 
products  of  the  workshops  of  the  unconscious  when  these  come  into 
relation  with  reality. 

In  ‘ the  unconscious  ’ there  are  preserved  not  only  perceptive- 
emotive  historical  realities,  but  also  intellectual  and  sentimental 
syntheses,  and,  further,  all  the  ideo-motor  and  senso-motor  associates, 
so  that  series  of  movements  may  be  effected  independently  of  will 
and  of  consciousness,  because  there  are  preformed  ideo-motor 
mechanisms. 

When  there  appears  in  the  illuminated  part  of  consciousness 
any  intellectual  synthesis,  such  as  an  object  of  study,  a state  of 
emotion,  or  an  interest,  and  the  order  for  action  is  given  to  the 
laboratories  of  unconsciousness,  work  is  immediately  begun,  and 
the  product  comes  forth  sooner  or  later  into  the  illuminated  field, 
more  or  less  perfect  in  proportion  to  the  wealth  and  the  efficient 
organization  of  the  unconscious.  If  a scholar  studying  a lesson  in 
the  evening  cannot  then  repeat  it,  yet  during  the  night  dreams  of 
what  he  could  not  remember  earlier  in  the  evening  and  recollects 
it  perfectly  next  morning  ; and  if  a student  who,  owing  to  some 
obstacle  to  memory,  cannot  remember  a word  rises  from  his  work, 
wanders  about,  and  thinks  of  something  else  until  at  some  favour- 
able moment — perhaps  the  next  morning — the  word  comes  to  his 


PSYCHIATRY 


398 

lips,  it  is  certainly  ‘ the  unconscious  ’ that  furnishes  to  consciousness  j 
all  that  he  has  been  seeking  for.  | 

The  speech  of  an  orator  who  improvises  and  the  genial  thought 
that  surprises  consciousness  itself  are  most  irrefragable  proofs  of  ' 
the  work  of  ‘ the  unconscious.’  Walking  and  avoiding  contact  with  ^ 
persons  while  attention  is  concentrated  on  some  other  matter  ; 
writing  a word  that  one  has  thought  of  or  seen  while  the  illuminated 
focus  is  occupied  by  something  else  ; the  unconscious  or  subcon- 
scious movements  of  mediums,  not  due  to  hazard,  but  following  , 
a logical  direction  that  proves  the  existence,  alongside  of  conscious  1 
thought,  of  another  collateral  thought  outside  of  consciousness 
(Janet,  Automatisme  psychologique)  \ the  words  written  by  the 
hysterical  woman  in  whose  anaesthetic  hand  a pen  has  been  placed 
in  position  for  writing,  without  her  perceiving  it  or  knowing  any- 
thing of  it — all  these  are  common  examples  of  the  activity  of  ‘ the 
unconscious.’  It  is  in  unconsciousness  that  the  formations  of  delirium 
are  prepared  and  organized,  that  they  assume  associative  relations 
and  raise  the  potential  of  the  sensory  zones,  producing  hallucina- 
tions as  a result.  It  is  to  ‘ the  unconscious  ’ that  are  relegated  these 
syntheses  of  contrast  that  have  a tendency  to  invade  the  illuminated 
field  of  consciousness.  It  is  ‘ the  unconscious  ’ that  furnishes  the 
images  of  dreams  and  the  plastic  pictures  of  hysteria  and  of  som- 
nambulism. ‘ The  unconscious  ’ is  the  great  architect  of  good  and 
of  evil,  of  genius  and  of  folly,  and  the  majority  of  mental  affections 
have  their  origin  in  it. 


Consciousness,  considered  as  a whole,  has  its  anatomical  sub- 
stratum in  all  the  cerebral  mantle.  We  might  speak  of  as  many 
components  of  consciousness  as  there  are  qualities  of  the  outer 
world  perceived,  these  qualities  corresponding  to  the  sensory  areas 
of  the  mantle  and  the  forms  of  reaction  of  the  tactile-motor  zone. 
If,  therefore,  there  exists  a cerebral  area  in  which  the  fusion  of  the 
products  of  the  sensory  zones  takes  place,  and  the  intellectualization 
of  the  fundamental  emotions  ; if,  as  a matter  of  fact,  the  intellectual- 
emotive  and  the  motor  syntheses  evoke  their  separate  components 
from  their  respective  sensory  seats,  which  hold  themselves  in  readi- 
ness for  orders  from  a superior  centre  ; if  there  is  a field  in  which 
the  syntheses  of  contrast  are  formed  and  the  motives  of  action  are 
balanced  in  the  presence  of  desire  ; if  logical  thought  passes  over 
the  illuminated  field,  controlled  by  reality,  present,  past,  or  future 
(imagination),  that  cerebral  area — of  winch  we  presuppose  the 
existence  — in  which  these  high  functions  are  performed,  is  the 
area  of  the  frontal  lobes. 

I liave  already  said  in  the  first  part  of  this  work  that  the  frontal 
lobes  reassume,  co-ordinate,  and  control  the  work  of  the  sensory 
and  motor  zones.  The  power  of  the  personality  arises  from  the 


CONSCIOUSNESS 


3 


relations  of  co-ordination,  subordination,  and  discipline  existing 
between  the  sensory  and  motor  zones  and  the  frontal  lobes,  always 
supposing  that  the  whole  mantle  has  reached  its  normal  develop- 
ment. 

In  the  degrees  of  formative  and  conservative  power  of  the  sen- 
sory zones,  in  the  extent  of  the  power  of  synthesis,  and  in  the 
degree  of  co-ordination  and  subordination  of  the  sensory  products 
to  those  of  the  mental  syntheses,  we  may  recognise  gradations  of 
consciousness.  The  predominance,  in  their  reciprocal  relations,  of 
the  sensory  areas  over  the  area  of  synthesis  and  control,  which  gives 
the  norm  to  life,  is  the  highest  and  surest  note  of  degeneration. 
Now,  it  is  evident  that,  if  the  premises  are  sound,  the  chief  centre 
of  consciousness,  coinciding  with  the  portion  of  its  field  that  is  most 
highly  illuminated,  must  correspond  with  the  frontal  lobes.  I 
would  offer  the  hypothesis  that  the  sleep  of  the  normal  man  depends 
upon  those  lobes  being  in  repose.  During  sleep  the  sensory  zones 
operate  in  a disorderly  fashion,  being  without  control  in  their  rela- 
tion to  reality  (dreams).  In  somnambulism  the  frontal  lobes  are 
probably  subordinated  to  the  power  of  the  sensory  zones  in  activity. 
These  latter  even  furnish  some  of  the  syntheses  that  are  at  the 
service  of  the  sensory  images  called  up,  some  of  them  of  extraordinary 
vivacity — hallucinations,  recollections.  Perhaps  the  amnesia  of 
the  somnambulist  is  to  be  explained  by  the  awakening  to  life  of 
the  frontal  lobes  that  have  exercised  no  control  during  the  som- 
nambulism (just  as  they  exercise  none  during  sleep),  and  have 
evoked  no  images  (amnesia  in  duplication  of  the  personality). 

Hallucinations  are,  at  bottom,  only  the  result  of  the  predominant 
functional  activity  of  the  sensory  zones,  whose  products  not  only 
elude  the  control  of  the  frontal  lobes,  but  very  often  subject  the 
frontal  lobes  to  the  controlling  power  that  they  exercise  over  the 
whole  mental  life.  The  small  circuits  of  human  action,  automatism, 
instincts,  ideo-motor  and  senso-motor  reflexes,  are  more  accessible 
when  there  is  obstruction  of  the  large  circuits  that  pass  through 
the  centre  controlling  the  syntheses  — that  is,  through  the  most 
highly  illuminated  part  of  the  field  of  consciousness.  There  alone 
the  motives  are  in  contact  with  counter-motives  (syntheses  in- 
hibiting action,  and  syntheses  directing  action). 

In  deficient  development  of  the  frontal  lobes  and  of  their  func- 
tions, and  in  inharmonious  relations  between  them  and  the  sensory 
areas,  we  may  find  the  anatomico-physiological  substratum  of  a 
large  group  of  mental  maladies.  Many  forms  of  insanity  are  simply 
thebffect  of  the  infraction  of  the  laws  of  co-ordination  and  subordina- 
tion of  the  separate  parts  of  the  mantle.  The  tracts  of  the  mantle 
that  are  in  rebellion  introduce  new  components  into  consciousness, 
and  withdraw  the  personality  from  the  rigorous  control  of  reality, 
or  they  forbid  or  lead  astray  its  normal  action.  In  sensory  insanity, 
in  paranoia,  in  obsession,  in  delinquency,  it  is  clear  that  the  mental 


400 


PSYCHIATRY 


proletariat  is  in  rebellion  against  the  ruling  powers  of  the  mind, 
which  may  have  become  enfeebled  or  decayed  ; or  the  rebels  may 
be  new  products  that  transgress  the  laws  of  co-ordination  and 
subordination.  | 

Consciousness,  therefore,  is  mutable.  The  conditions  of  its ! 
normal  changes  are  determined  by  contact  with  present  reality  on 
the  one  hand,  and  by  uninterrupted  relations  with  its  own  history  , 
on  the  other.  Action  that  has  been  deliberated  upon  in  the  luminous 
field  of  consciousness  draws  from  the  perception  of  reality,  and  from 
the  past  history  of  the  consciousness,  the  attributes  of  utility  and  of 
beneficiality.  It  is  in  this  way  that  the  character  of  the  personality 
is  maintained.  Mental  disorder,  independent  of  the  degree  of 
evolution  of  the  consciousness,  is  the  detachment  of  consciousness 
from  reality,  or  the  separation  of  the  actual  consciousness  from  its 
past  experiences. 

We  shall  find  this  fundamental  conception  always  applicable 
in  the  study  of  mental  affections  that  we  are  about  to  enter  upon. 
To  the  analysis  of  these  affections  the  third  part  of  this  work  is. 
devoted. 


PART  III 


CHAPTER  I 

METHODS  AND  FIELD  OF  CLINICAL  INQUIRY 

The  exposition  of  psychological  phenomena  and  their  teaching 
given  in  the  second  part  of  this  treatise  reflects  general  psychology, 
normal  and  morbid.  In  this  third  part  it  is  our  aim  to  translate  the 
facts  and  laws  of  general  psychology  into  what  is  known  as  individual 
psychopathology,  since  in  each  individual  case  the  task  of  the 
physician  is  to  reconstruct,  in  a mental  synthesis,  the  diseased 
personality  in  front  of  him,  taking  into  account  the  social  grade  of 
each  individual  and  the  amount  of  instruction  received. 

Such  a supreme  object  on  the  part  of  the  psychiatrist  may  be 
attained  by  means  of  (i)  the  psychological  examination,  dependent 
upon  the  interrogation  of  the  supposed  patient  ; (2)  by  the  re- 
construction of  the  individual  and  family  history  ; (3)  perhaps  also 
by  an  inquiry  into  the  environment  ; (4)  the  anthropological 
examination  ; (5)  the  minute  functional  examination  of  the  nervous 
system  ; (6)  the  examination  of  the  entire  organism,  taking  into 
account  the  multiple,  mediate,  and  immediate  relations  existing 
between  structure  and  function,  both  of  the  cerebrum  and  of  all  the 
other  organs,  inasmuch  as  all  these  in  synthesis  reflect  the  personality. 

The  first  task  of  the  physician,  then,  is  the  psychological  investi- 
gation, which  rests  for  the  most  part  on  the  interrogation  and  the 
knowledge  of  the  history  of  the  person  being  examined,  and  also  on 
his  conduct.  The  individual  concerned  may,  unconstrainedly  and 
with  the  utmost  good  faith,  express  his  whole  mind,  with  all  its 
anomalies  and  disturbances,  omitting  nothing  ; he  may,  however, 
simulate  or  dissimulate,  or,  again,  maintain  an  attitude  of  silence, 
no  matter  how  much  he  be  questioned. 

In  every  case  the  skill  of  the  physician  lies  beyond  all  else  in 
not  allowing  a single  word  to  escape,  not  an  act,  not  an  attitude, 
to  pass  unnoticed.  Every  movement  has  its  language  and  its  signifi- 
cance, every  word  must  be  watched. 

The  interrogation  should  be  so  directed  as  to  gauge  the  principal 

401  26 


402 


PSYCHIATRY 


mental  activities  which  we  have  expounded  in  the  second  part  of 
this  work  ; but  it  is  unnecessary  to  follow  a precise  and  identical 
order  in  every  case,  the  important  thing  being  to  investigate  fully 
and  well.  We  may  commence  with  the  examination  of  the  con- 
sciousness and  the  personal  identity.  What  I have  written  of  the 
consciousness  may  be  our  guide.  We  have  the  constituent  elements 
of  the  ego,  which,  according  to  Guislain,  must  be  the  guide  of  the 
physician  in  his  interrogation  of  the  patient.  We  must  construct 
it,  then,  with  a series  of  questions  : What  is  your  name  ? What  is 
your  age  ? What  trade  or  profession  do  you  follow  ? Are  your 
parents  alive  ? Have  you  any  relations  ? Are  you  married  ? 
Have  you  any  children  ? Where  do  you  come  from  ? or  where  do 
you  live  ? How,  and  on  what,  do  you  live  ? Have  you  any 
belongings  ? How  many  ? and  where  are  they  ? 

Once  we  have  obtained  the  general  details  that  furnish  the 
elements  for  the  identity,  one  of  two  methods  may  be  followed  : 
we  may  allow  the  patient  to  speak,  drawing  him  into  conversation, 
if  at  all  possible,  upon  whatever  subject  seems  most  appropriate, 
in  which  case  it  is  evident  that  the  physician,  if  he  is  familiar  with 
such  patients  or  if  he  has  had  a good  indication  of  the  patient’s 
peculiarities,  after  a longer  or  shorter  conversation,  will  be  in  a , 
position  to  appraise  the  perceptive  capacity,  memory,  attention, 
ideation,  etc.  ; or  we  may  adhere  to  a series  of  questions,  more  or  ' 
less  stereotyped  in  the  mind  of  the  alienist,  these  also  being  j 
disposed  in  groups  corresponding  to  the  different  forms  of  mental 
activity,  the  perceptive,  mnemonic,  attentive,  ideative  faculties,  ] 
etc.  In  any  case,  no  matter  what  the  method  preferred,  allow  the  ' 
patient  to  speak  whenever  he  shows  a tendency  to  do  so.  As  a 
rule,  the  person  under  examination  does  not  wait  for  the  physician 
to  produce  all  his  formulary,  but  speaks  for  himself  even  more  ;! 
than  the  physician  expects  or  desires.  j 

When  I think  of  the  great  variety  in  the  behaviour  of  the  insane,  | 
or  those  supposed  to  be  such,  I am  led  to  regard  as  almost  useless  ■ 
the  formularies  recommended  by  worthy  psychologists — e.g.,  that  ^ 
of  Ferrari,  in  favour  of  which  many  good  arguments  were  advanced  ^ 
at  the  Phreniatric  Congress  at  Naples,  1899.  Nevertheless,  if  the  - 
patient  speaks  only  when  interrogated,  some  method  indeed  must 
be  followed  ; every  question  must  have  its  object,  and  it  is  wise  to  i 
have  a definite  plan.  j 

In  such  a case  Ferrari’s  method  is  to  be  preferred  : 

I.  What  is  the  perceptive  capacity  of  the  individual  under  I 
examination  ? In  this  examination  we  proceed  from  the  simple  to  ^ 
the  complex,  following  out  practically  the  law  of  progressiveness.  I 
I myself  employ  a number  of  wooden  cubes  of  various  sizes  and  I 
colours,  with  letters  and  figures  of  common  objects  or  animals  on  I 
them,  placing  them  before  the  patient,  and  inviting  him  to  recognise  ■ 
forms,  colours,  and  figures  ; then  he  is  questioned  concerning  objects® 


METHODS  AND  FIELD  OF  CLINICAL  INQUIRY  403 


round  about  him,  and  their  use  ; next  concerning  persons  and  their 
attributes  ; then  as  to  the  place  (here  we  enter  into  several  par- 
ticulars) ; lastly,  concerning  the  day  of  the  month  and  year.  In  this 
way  we  judge  not  only  of  the  perceptive  capacity,  but  of  the  orienta- 
tion, or,  rather,  of  the  appreciation  of  self  in  time  and  space. 

In  putting  these  questions,  we  must  note  carefully  whether  the 
patient’s  mind  becomes  distracted,  whether  he  says  anything  in  an 
undertone  or  looks  towards  some  other  point,  thus  suggesting  the 
presence  of  hallucinations  ; or  we  put  some  questions  to  him  in 
this  regard  : Do  you  hear  any  voices  ? Do  they  sing  to  you  ? Do 
they  insult  you  ? Where  do  they  come  from — from  the  room,  from 
behind  the  wall,  from  the  roadway  ? Have  you  any  visions  ? Are 
they  of  persons,  animals,  or  supernatural  beings  ? What  attitude 
do  they  assume  towards  you  ? Do  you  have  any  dreams  ? Are 
they  fearful,  happy,  or  significant  ? 

2.  The  examination  of  the  memory  is  next  taken  up,  and  is 
effected  with  the  aid  of  appropriate  questions  : How  old  are  you  ? 
Where  were  you  educated  ? What  were  your  teachers’  names  ? 
your  father’s,  mother’s,  brothers’,  and  sisters’  ? Where  do  you 
live  ? Did  you  live  in  any  other  house  before  this  one  ? How 
long  have  you  been  in  the  asylum  ? Who  brought  you  here  ? What 
doctor  first  examined  you  ? Where  and  how  did  he  examine  you  ? 
What  treatment  have  you  received  ? What  relations  or  friends  have 
come  to  visit  you  ? What  kind  of  food  had  you  yesterday,  and  for 
the  last  few  days  ? 

3.  We  then  pass  to  the  examination  of  the  ideation,  inviting  the 
patient  to  form  a series  of  reasonings,  which  are  also  intended  to 
measure  to  a certain  extent  his  attentive  capacity : Why  did  you 
prefer  your  present  trade  (or  studies)  ? What  do  you  think  of 
your  confinement  in  the  asylum  ? Why  have  they  sent  you  here  ? 
What  do  you  intend  to  do  when  you  get  away  ? What  are  the 
nurses  and  the  doctors  doing  for  you  ? Why  did  you  do  such  and 
such  a thing  ? What  object  did  you  wish  to  attain  ? Are  you 
better  here  than  at  home  ? How  much  is  necessary  to  support  your 
family  in  a proper  manner  ? Whence  do  you  procure  the  requisite 
funds  ? What  is  your  income  ? What  do  you  get  for  your  work  ? 
Which  of  the  members  of  your  family  assist  in  the  maintenance  of 
the  house,  either  with  income  or  with  work  ? To  what  extent  ? 
In  what  manner  do  you  expend  this  sum  ? Give  a calculation  of 
the  cost  of  living,  of  the  house  rent,  of  clothing,  and  the  amount  neces- 
sary for  the  education  of  your  children.  (It  is  very  natural  that 
the  examination  should  vary  as  regards  this  scheme  of  judgments, 
comparisons,  calculations,  etc.,  according  to  the  degree  of  culture 
■of  the  individual.  If  we  have  in  front  of  us  a literary  person,  we 
will  bring  the  conversation  round  to  some  author  and  to  literary 
questions  ; if  he  is  a traveller,  we  will  invite  him  to  express  judg- 
ments on  the  countries  he  has  visited,  upon  distances,  etc.  ; if  a 

26 — 2 


404 


PSYCHIATRY 


peasant,  on  the  methods  of  agriculture,  on  the  crops,  the  rent,  the 
leases,  etc.). 

As  a rule,  the  individual  under  examination,  in  the  course  of  his 
replies,  even  when  he  does  not  spontaneously  manifest  his  false 
ideas,  gives  some  indication  for  the  more  direct  investigation  of 
deliria,  which  presents  some  difficulty  only,  or  almost  only,  amongst 
paranoics.  To  them  we  must  put  our  questions  in  such  a way  as 
not  to  show  any  apparent  interest  in  knowing  their  affairs.  To  the 
common  questions.  Have  you  any  enemies  ? What  are  your  rela- 
tions with  the  Divinity  ? etc.,  only  the  paranoics  of  long  standing 
reply,  precisely  those  who  experience  no  difficulty,  because  they  no 
longer  have  any  reason  to  be  silent  or  self-contained. 

At  the  outset  of  the  illness  there  should  be  a special  conversation 
with  the  patient,  having  for  its  object  the  investigation  of  the  deliria. 
The  alienist  must  exercise  the  greatest  skill  and  tact  in  order  to 
insinuate  himself  successfully  into  the  mind  of  his  patient  ; he  must 
wheel  him  round,  and  attack  him  from  every  side,  for  it  is  neither 
advantageous  nor  commendable  to  approach  the  patient  with  a 
stereotyped  formulary  of  interrogations. 

The  interrogatory  for  the  investigation  of  the  state  of  the  senti- 
ments and  emotions  is  somewhat  more  difficult  and  less  promising, 
since  the  affectivity  must  be  judged  by  the  patient’s  behaviour 
and  actions,  besides  the  relations  he  maintains  with  his  family, 
in  his  office,  and  in  his  social  environment,  rather  than  by  the 
verbal  replies  of  the  supposed  lunatic  ; sometimes  it  is  necessary 
to  surprise  the  behaviour  and  attitudes  of  the  person  under  examina- 
tion at  different  hours,  both  day  and  night.  Grief,  fear,  joy,  anger, 
suspicion,  pride,  hatred,  are  revealed  by  other  means  than  the 
interrogatory.  He  is  a very  ingenuous  physician  or  judge  who 
thinks  he  can  penetrate  the  darkest  depths  of  the  human  mind  with 
four  questions,  be  they  ever  so  crafty  and  insinuating.  The  senti- 
ments present  the  largest  field  of  simulation,  dissimulation,  false- 
hood, and  all  those  artifices  which  must  serve  to  cover  ugliness 
of  the  mind  of  the  human  being,  just  like  the  cosmetics  which 
serve  to  cover  the  uncomeliness  of  the  fading  complexion  of  a 
conceited  woman.  The  questions  serve,  at  the  very  most,  to  let 
us  know  whether  the  individual  under  examination  has  or  has  not 
moral  notions — a very  different  thing  from  moral  sentiments  {vide 
Chap.  V.,  p.  362  et  seq.).  Ask  a person  under  examination,  ‘ Do 
you  love  your  mother  ?’  and  he  will  invariably  reply  ‘Yes’  (when 
it  suits  him  to  reply),  even  when  that  ‘ yes  ’ stands  out  in  contra- 
diction to  the  numberless  griefs  inflicted  by  him  on  his  mother. 

‘ Are  you  aware  that  the  property  and  the  wife  of  another  are  to 
be  respected  ?’  The  invariable  reply  is,  ‘ Certainly.’  Such  a 
reply  may  be  given  perhaps  by  a professional  thief  or  a profes- 
sional bully.  The  sentiments  are  better  investigated  by  other 
means  than  questions.  We  must  draw  the  elements  for  our  judg- 


METHODS  AND  FIELD  OF  CLINICAL  INQUIRY  405 


ments  from  a very  different  source,  for,  whatever  the  replies  given 
by  the  patient,  they  have  to  be  put  into  quarantine  to  await  control 
in  the  story  of  his  life  and  conduct,  which  story  should  be  carefully 
collected  and  recorded.  His  conduct  and  behaviour  in  the  family 
circle  and  in  the  social  relations  will  furnish  all  the  data  for  a judg- 
ment on  the  emotions  and  the  sentiments.  We  must  inquire  also 
if  the  individual  under  examination  had  a tendency  to  melancholy 
or  was  of  a cheerful  disposition  ; if  he  was  fond  of  solitude  or  was 
of  a sociable  nature  ; if  he  was  inclined  to  be  silent  or  to  stammer  ; 
if  he  was  timid,  courageous,  or  bold,  calm,  irascible,  or  choleric  ; 
if  modest  or  proud,  suspicious  or  assured  ; if  fond  of,  or  indifferent 
to,  his  family  ; if  fulfilling  his  duties  and  adapted  to  the  discipline 
of  the  family,  the  school,  or  the  office,  or  negligent,  undisciplined, 
deaf  to  appeals  ; if  respectful  to  others  and  of  others’  property,  or 
egoistic  and  insensible  to  the  sufferings  or  interests  of  others  ; if 
cruel  to,  or  sympathetic  with,  men  or  animals  ; if  he  was  religious 
or  not  (taking  into  account  the  domestic  environment),  and  especially 
if  he  had  ascetic  tendencies  ; how  he  esteemed  friendship,  how  the 
instinct  or  sentiment  of  love  was  developed  in  him  ; if  an  adult, 
how  he  fulfilled  his  social  duties  ; whether  he  had  an  artistic  tem- 
perament, etc.  With  regard  to  one  sentiment  alone  is  it  necessary 
to  pursue  inquiry  with  the  aid  of  questions,  and  that  is  the  kin- 
iesthetic  sense  : How  do  you  feel  ? Are  you  suffering  from  any- 
thing ? Do  you  feel  strong  ? Are  your  legs  able  to  carry  you  a 
long  distance  ? Do  your  hands  serve  you  with  their  accustomed,  or 
more  than  their  accustomed,  ability  ? Are  you  passionate  in  love 
(if  a man)  ? Do  you  ever  suffer  from  headaches,  or  from  oppression 
in  the  region  of  the  stomach  ? Have  you  a good  appetite  ? 

The  inquiry  is  then  prosecuted  by  the  examination  of  the  motor 
determinism,  suggested,  commanded,  and  spontaneous.  The  insane 
assume  a number  of  strange  attitudes,  and  perform  illogical  acts 
1 to  such  an  extent  that  it  would  be  impossible  to  pass  them  in  review. 
During  a visit  to  an  asylum  ward,  no  matter  how  little  the  vigilant 
discipline  may  be  relaxed — discipline  whose  aim  is  to  hinder  certain 
, manifestations  and  to  reconform  the  abnormal  or  illogical  tendencies 
j to  the  ordinary  rules  of  life — it  frequently  happens  that  a patient 
I may  be  seen  sitting  up  in  bed,  her  face  in  her  hands,  and  her  hair 
(untied,  or  carrying  on  an  imaginary  conversation  in  a low  voice 
with  a vision  of  herself,  her  eyes  turned  towards  one  corner  of  the 
room  or  to  the  window,  or  crouched  and  self-concentrated,  or 
skipping  merrily  round  you,  or  kneeling  to  kiss  your  feet,  or  cursing 
■from  afar,  or  collecting  every  possible  thing — paper,  rags,  scraps 
of  food — and  filling  enormous  pockets,  which  have  to  be  emptied, 
or  performing  the  toilet,  decorated  with  rags  and  ribbons  of  the 
most  striking  colours,  strangely  disposed  among  the  hair  and  the 
clothing,  or  standing  at  the  bedside  undressed,  exposing  the  genitals 
tmost  frequent  in  women),  etc. 


li 


4o6 


PSYCHIATRY 


All  these  attitudes  and  all  these  actions  are  only  reflexes  of 
the  new  orientation  of  the  personality,  of  the  predominating  emotions 
and  false  ideas,  of  repeated  sensory  disturbances,  or  else  they  are 
motor  stereotypes,  traces,  residua,  of  a new  and  abnormal  mental 
organization,  which  also  becomes  dissolved. 

A patient  in  the  clinique  at  Palermo,  from  morning  till  night 
regularly  every  six  or  seven  minutes,  used  to  attack  the  garden 
wall,  using  one  hand  as  a shield  and  with  the  other  brandishing 
an  imaginary  weapon,  advancing  with  angry  threats  and  his 
head  inclined  in  the  attitude  of  an  athlete  or  a duellist,  then  retiring 
quietly  to  his  place.  Another  used  to  cry  out  frequently  during 
the  day,  but  especially  in  the  morning,  with  all  his  might,  ‘ I 
am  the  Lord  of  the  world  !’ 

We  must  take  account  of  all  these  manifestations  and  all  these 
attitudes,  each  of  which  is,  as  it  were,  a stone  which  serves  for 
the  construction  of  the  diagnostic  edifice,  and  which  assists  us  in 
reconstructing  the  story  of  the  illness,  and  in  portraying  the  char- 
acter of  the  personality  as  it  existed  previous  to  the  illness. 

Next  we  investigate  the  conative  activity.  The  patient  may 
be  ordered  to  perform  a series  of  more  or  less  complex  movements  : 
Stand  up  ! Walk  in  that  direction  for  ten  paces  ! Raise  the 
right  hand  ! Carry  the  chair  to  that  corner  ! Write  your  name  ! 
It  will  be  seen  that  one  does  not  make  any  response  at  all  to  the  . 
command  ; another  obeys  in  part,  and  stops  ; another  fulfils  a . 
different  act  from  that  ordered  ; another  looks  at  you  with  a frown  ; 
whilst  others  obey  with  more  or  less  activity.  J 

Next  we  pass  to  another  order  of  psychological  investigations,  * 
which  can  only  be  fulfilled  in  large  institutions.  To  this  inquiry, 
as  may  readily  be  understood,  only  a few  patients  lend  themselves. 

We  measure  the  time  of  reaction  under  diverse  stimuli — tactile,  ; 
acoustic,  visual — likewise  the  time  required  for  selection,  and  \ 
this  also  gives  a measure  of  the  attentive  and  perceptive  capacity,  | 
by  complicating  the  stimuli.  For  this  purpose  the  chronoscope  j 
of  Hipp  or  Arson val  is  of  great  service.  For  the  measure  of  the  '■! 
memory  we  investigate  the  fixative  capacity  and  that  of  conserva-  ^ 
tion  (retentive).  We  present  to  the  person  under  examination  . 
series  of  letters,  syllables,  words,  or  figures  for  a determined  time, 
and  invite  him  to  repeat  the  series  (whether  seen  or  heard)  in  speech  . 
or  writing,  after  some  minutes,  after  the  lapse  of  an  hour,  after  ^ 
several  hours,  and  late  on  the  following  day.  1 

For  the  measure  of  attention  in  everyday  practice  I have  some. I 
time  preferred  Miinsterberg’s  method,  which  consists  in  inviting  the! 
patient  to  trace  simultaneously  vertical  lines  with  the  right  hand! 
and  horizontal  lines  with  the  left.  In  proportion  as  the  attention^ 
becomes  fatigued  we  get  a measure  (with  a chronometer  or  a pen-B 
dulum  or  a pin  working  on  a Facault  cylinder  on  which  hasB 
previously  been  traced  the  time  of  a diapason  at  fifty  vibrations* 


METHODS  AND  FIELD  OF  CLINICAL  INQUIRY  407 


per  second)  of  the  time  between  the  commencement  of  the  move- 
ments and  that  of  distraction.  When  the  movements  of  the  two 
hands  tend  to  have  the  same  direction,  vertical  or  horizontal, 
distraction  commences,  and  the  time  of  attention  will  be  measured 
by  the  distances  of  the  threshold  of  fatigue  which  can  be  represented 
in  comparable  diagrams. 

As  regards  ideation,  in  addition  to  applying  the  interrogatory, 
it  is  well  to  measure  the  associative  and  imaginative  capacities. 

In  the  case  of  the  associative  capacity,  the  simplest  method 
is  that  of  pronouncing  a word  or  showing  it  for  a second  or  two 
in  the  camera  obscura  of  Buccola,  illuminated  by  a Geissler’s  tube 
(experiment  of  Guicciardi  and  Dandolo),  or  of  writing  it  before  him. 
The  individual  under  examination  should  pronounce  in  a deter- 
mined time  (forty  to  sixty  seconds)  all  the  words  that  reflect  images 
revealed  by  the  word  heard,  shown,  or  written.  The  number  of 
images  reawakened  (it  differs  greatly  in  the  three  methods  for  the 
same  individual)  gives  the  measure  of  the  associative  capacity  in 
the  given  unit  of  time,  and  may  be  put  into  the  form  of  an  equation 
in  which  the  denominator  as  is  divided  by  the  time  s.  For  the 
imaginative  capacity  we  can  follow  the  method  of  the  ink-spots 
of  Dearbon  {vide  p.  312). 

The  measure  of  the  emotions — that  is,  of  the  fundamental 
emotions — is  obtained  by  means  of  tracings  of  the  respiration 
(pneumography)  and  of  the  capillary  circulation  obtained  with 
the  gauntlet  of  Patrizi,  which  is  rather  easier  in  application  than 
Mosso’s  plethysmograph.  I will  reproduce  some  of  these  tracings 
when  dealing  with  the  individual  forms  of  disease. 

The  ergograph  is  a good  and  relatively  easy  means  of  investi- 
gating the  measure  of  voluntary  muscular  energy  and  the  manner 
of  its  manifestation.  The  ergographic  tracings  vary  greatly  in 
the  various  psychopathic  forms,  and  may  serve  also  as  proof- 
tests  of  the  modifications  the  disease  is  undergoing,  as  well  as  a 
means  of  instruction. 

The  psychological  examination  is  completed  by  the  writing  of  the 
patient,  whenever  possible.  In  no  other  way  does  he  so  clearly 
reveal  his  thoughts  as  in  writing. 

The  superficialities,  the  incoherencies,  the  paradoxes,  the  deliria, 
the  amnesiae,  are  well  brought  into  evidence.  The  writing  of  the 
insane  person,  as  indeed  of  anyone  of  whom  a psychological  examina- 
tion is  desirable,  is  always  a precious  document  to  the  psychologist. 

The  psychological  examination  which  every  experienced  phy- 
sician attempts  to  execute  on  the  lines  traced  above,  even  when 
he  has  at  his  disposal  the  very  best  means,  is  gradually  completed 
by  the  functional  examination  of  the  nervous  system.  All  the 
forms  of  sensibility  should  be  investigated  ; all  the  special  senses,  as 
well  as  the  mobility  and  the  state  of  the  muscles,  the  superficial  and 


4o8 


PSYCHIATRY 


deep  reflexes,  etc.,  should  be  examined,  nothing  being  excluded. 
None  of  the  facts  belonging  to  the  semeiology  of  the  nervous  I 
system  should  escape  notice,  inasmuch  as  every  one  of  them  can  ! 
furnish  some  datum  for  the  more  precise  cognition  of  the  subject 
examined.  I 

For  the  particulars  concerning  the  signification  of  the  individual  - 
symptoms,  and  the  methods  for  the  most  rigorous  investigation  of 
these,  I must  of  necessity  refer  the  reader  to  the  special  treatises  on  ^ 
the  semeiology  of  the  diseases  of  the  nervous  system  (Bianchi,  L., 
Semeiotica  delle  malattie  nervose  ; Morselli,  Semeiotica  delle  malattie 
mentali).  I 

Particular  attention  must  be  paid  to  the  so-called  degenerative  I 
anthropological  signs.  Taking  into  account  race,  climate,  and  epoch, 
the  human  form  presents  particular  characteristics,  on  the  recurrence 
and  grouping  of  which  depends  the  normal  type  of  each  race. 

Anything  in  the  configuration  of  the  individual  that  constitutes 
a deviation  from  the  mean  type  of  the  race,  that  exhibits  character- 
istics of  inferior  races  or  even  of  higher  animals,  or  produces  irregu- 
larities or  asymmetries,  may  be  considered  as  a characteristic  of 
degeneration.  It  is  well,  however,  to  come  to  an  understanding  as 
regards  these  signs  of  degeneration,  inasmuch  as  we  will  not  classify 
among  degenerates  an  individual  who  bears  only  one  of  the  so-called 
degenerative  stigmata.  Only  when  these  have  a very  high  value  per  \ 
se — as,  for  example,  microcephaly  or  hydrocephaly — can  we  speak  ; 
of  degeneration  or  of  an  anomalous  or  morbid  anthropological 
constitution.  An  individual  cannot  be  regarded  as  a degenerate  ^ 
unless  he  bears  many  degenerative  signs,  from  the  sum  total  of  ! 
which  he  appears  manifestly  to  be  an  inferior  and  anomalous  type. 
Apart  from  distinct  exaggerations,  a solitary  degenerative  sign, 
such  as  we  may  meet  with  in  the  majority  of  healthy  individuals,  ; 
does  not  constitute  an  element  in  anthropological  judgment.  j 

According  to  Marro,  such  signs  of  degeneration  may  be  divided  j 
into  three  categories  : (i)  Atypical ; (2)  atavic  ; (3)  pathological.  \ 
The  atypical  characteristics  are  simple  deviations  from  the  ordinary  i 
type  of  the  race ; the  atavic  signs  are  reproductions  of  old  forms  ^ 
that  have  disappeared  with  evolution  through  series  of  generations  ; 
the  pathological  characteristics  are  the  consequence  of  morbid  pro- 
cesses which  leave  more  or  less  distinct  deformities.  These  three 
groups  may  be  reduced  to  two,  since  the  atypical  is  most  frequently 
either  pathological  or  atavic  ; the  first  and  second  groups,  however, 
give  a proportion  numerically  inferior  to  the  third,  for  the  investiga- 
tions of  \irchow,  and  others  after  him,  have  given  ample  evidence 
that  the  pathological  processes,  especially  deviations  in  the  process  i. 
of  ossification  of  the  sutures,  rickets,  and  diseases  of  the  foetus,  are  1 
a cause  of  more  or  less  pronounced  anomalies,  and  are  relatively  I 
frequent.  1 

I give  here  a brief  index  of  the  more  important  degenerative  I 


METHODS  AHD  FIELD  OF  CLINICAL  INQUIRY  409 


I 

signs  that  must  be  sought  for  in  each  case,  referring  to  the  work 
of  Lombroso  (Uuomo  delinqusntc,  ultimo  ediz.,  and  Recherches 
T Anthropologic  criminellc),  Angiolella  {Manuale  di  Antropologia 
criminale  ad  uso  dei  medici,  1897),  and  many  others,  for  the  methods 
of  investigation  and  for  a more  systematic  study  of  the  subject. 

Stature. — With  respect  to  stature,  it  is  necessary  to  note  the 
presence  of  dwarfism  and  giantism,  besides  an  excessive  length  of  the 
span  of  the  arms  (measured  from  the  extremities  of  the  middle 
fingers  with  the  arms  stretched  out  horizontally  at  the  level  of  the 
shoulders),  the  measure  of  which  is  normally  equal  to  the  stature. 

In  the  Cranium. — The  total  circumference  (passing  over  the 
glabella  above  the  superciliary  ridges,  and  through  the  occipital 
point),  inferior  in  man  at  54  and  superior  at  58  centimetres  ; low, 
receding,  or  narrow  forehead  (stenocrotaphia) ; flat  occiput ; 
marked  asymmetry,  such  as  frontal  or  occipital  plagiocephaly ; 
oblique  cranium  (Lasegue)  ; scaphocephaly,  oxycephaly,  trigono- 
cephaly, platycephaly,  ultra-dolicocephaly,  and  ultra-brachy- 
cephaly  (crania  too  long  or  too  large),  are  all  anomalous. 

The  cranial  capacity,  approximately  estimated,  may  be  too  low 
(below  1,400  c.c.)  or  too  high  (above  1,600  c.c.).*  In  taking  these 
measures,  it  is  necessary  to  take  account  of  those  degenerative 
signs  that  are  indicative  of  deficiency  of  the  cranial  capacity  ; 
among  these  are  marked  projection  of  the  glabella,  the  superciliary 
arches  (through  abnormal  development  of  the  frontal  sinuses),  and 
the  occipital  protuberance,  which  sometimes  is  prolonged  into  two 
transverse  crests,  separated  by  a sulcus  (torus  occipitalis  trans- 
versus). 

In  the  Face. — Disproportionate  size  with  respect  to  that  of  the 
cranium  ; protruding  zygomata  (increased  length  of  the  bizygomatic 
diameter)  ; large  mandible  ; lemurian  form  of  the  maxillary  angles. 
With  the  disproportionate  size  of  the  maxilla  there  is  frequently 
associated  enormous  development  of  the  muscles  of  mastication, 
the  masseters  and  the  temporals  ; the  insertion  of  these  muscles  is 
higher  than  usual,  and  their  greater  development  assists  in  giving 
the  illusion  of  a cranium  larger  than  is  really  the  case.  Prognathism, 
either  total  or  of  the  upper  or  lower  maxilla  alone,  or  simply  alveolar, 
and  exaggerated  abnormal  flattening  (orthognathism).  The  face  too 
small  (microprosopia)  ; facial  asymmetry  (plagioprosopia)  ; the 
orbital  apophyses  projecting  greatly  ; the  root  of  the  nose  greatly 
hollowed  ; flat  nose,  deviated  nose  ; excessively  deep  orbits  ; uni- 

“ * We  estimate  this  capacity  by  summing  together  the  ciphers  of 

(a)  the  maximum  horizontal  circumference,  (6)  the  longitudinal  curve 
(measured  between  the  glabella  and  the  most  prominent  occipital  point), 
(c)  the  transverse  curve  (measured  between  the  two  auditory  openings, 
passing  over  the  vertex),  {d)  the  maximum  antero-posterior  diameter 
(glabella  to  the  most  projecting  occipital  point),  and  {e)  the  maximum 
transverse  diameter  (between  the  most  distant  and  projecting  points  of  the 
parietal  eminences). 


410 


PSYCHIATRY 


lateral  or  bilateral  microphthalmia ; different  pigmentation  of  the 
irides. 

Ears. — Asymmetrical  ; the  auditory  canals,  placed  on  two 
different  axes  in  either  an  antero-posterior  or  a vertical  plane  ; lop- 
ears,  ears  flattened  out  or  otherwise  deformed  ; Darwin’s  tubercle  ; 
sessile  lobule. 

In  the  Mouth.  — Notable  distance  of  the  dental  diastem  (the 
distance  between  the  two  median  incisors),  or  fusion  of  the  two 
median  incisors,  giving  rise  to  three  instead  of  four  (an  anomaly 
I have  met  with  on  only  one  occasion)  ; canines  protruding  far 
beyond  the  level  of  the  other  teeth  ; bad  setting  of  the  teeth  ; 
narrowness  and  marked  arching  of  the  hard  palate  ; markedly 
flat  palate  ; bifid  uvula  ; wolf  mouth. 

In  the  Genitals. — Penis  too  small  or  too  large  ; congenital 
phimosis  ; epi-  or  hypo-spadias  ; monorchism,  or  cryptorchism  ; 
absence  of  nemasperms  in  the  semen  (which  I have  met  with  more 
frequently  than  one  would  believe,  even  when  coitus  takes  place 
regularly  and  the  semen  has  the  normal  appearance)  ; pronounced 
varicocele ; small  uterus  or  uterus  bicornis ; narrow  vagina,  or  vagina 
divided  by  a septum  ; highly  developed  clitoris  ; hermaphroditism. 

In  the  Trunk. — Thoracic  asymmetry  (Zuccarelli). 

In  the  Skin. — Mongolian  coloration  ; absence  of  hair,  or  hair  long, 
thick,  and  shaggy  over  all  the  body  ; albinism  ; red  skin. 

In  the  Limbs. — Asymmetry  in  the  length  of  the  upper  limbs  ; 
the  fingers  small  and  united  to  one  another  by  a kind  of  membrane 
that  brings  to  mind  webbed  feet  (Penta)  ; macrodactylism  or 
polydactylism  (Penta)  in  the  hands  or  feet  ; rudimentary  hand 
or  foot,  and  other  anomalies. 

Here  we  have  made  mention  only  of  the  principal  degenera- 
tive characteristics  ; for  fuller  details  consult : Lombroso,  Uonio 
delinquente  ; Virgilio,  Centuria  di  delinquenti,  1889  ; Marro,  Caratteri 
dei  delinquenti,  1887  ; Tonnini,  Le  epilessie ; Penta,  Annali  di 
Nevrologia,  1894  ; and  then  Thomson,  Carrara,  Sergi,  Tanzi, 
Benedikt,  and  as  m.any  others. 

The  anthropological  examination  and  the  functional  examination 
of  the  nervous  system,  besides  the  psychological  inquiry,  should  be 
followed  by  the  medical  examination.  The  alienist  must  not  forget 
the  genetic  connection  of  many  mental  affections  with  pathological 
organic  conditions.  He  must  remember  that  the  organic  states 
exert  a great  influence  upon  the  state  of  the  mind  and  the  currents 
of  thought  ; that  they  concur  in  the  constitution  of  the  fundamental 
feeling  which  is  a substratum  of  the  whole  psychic  life — viz.,  the 
kina,^sthetic  sense — and  that  alterations  of  this  feeling  close  certain 
jxiths  to  the  emotions  and  thoughts,  whilst  opening  up  others  ; that 
vascular  alterations  have  extremely  close  relations  with  the  nutrition 
of  the  central  organ  of  thought  ; that  defects  and  deviations  of  the 
molecular  interchange — the  arthritic  diathesis,  diabetes,  etc. — pro- 


METHODS  AEW  FIELD  OF  CLINICAL  INQUIRY  41 1 


foundly  disturb  the  disposition  of  the  mind,  the  mental  mechanism, 
and  sometimes  the  nutrition  of  the  brain  ; that  an  impoverished 
blood  cannot  give  rise  to  a cerebral  function  equally  efficacious  to 
that  given,  cceteris  paribus,  by  normal  blood  ; that  if  the  toxic 
products  of  the  tissues  do  not  become  regularly  eliminated  they 
obtain  entrance  into  the  blood-stream,  and  are  the  direct  and 
immediate  cause  of  a large  number  of  mental  affections  in  predisposed 
individuals.  The  alienist  is  a physician — no  more  than  a physician. 
He  has  in  the  insane  person  under  his  charge  a diseased  person, 
and  nothing  else  than  a diseased  person,  and  the  psychological  and 
anthropological  examination  should  complete  the  general  medical 
examination  ; with  respect  to  other  physicians,  he  has  only  a larger 
complement  of  culture  and  of  professional  and  social  duties. 

Acquaintance  with  the  family  and  the  social  and  climatic 
environment  is  even  more  important  to  the  alienist  than  to  the 
general  physician. 

The  family  and  the  social  environment  prepare  all  the  elements 
of  insanity  and  other  psychic  anomalies  ; these  only  require  to  be 
synthetized  in  the  individual  in  the  morbid  clinical  form,  to  which 
the  physician  then  gives  a name.  The  family  is  considered  with 
respect  to  heredity  and  the  environment  it  has  formed  for  the 
individual.  Disorder,  lack  of  discipline,  anarchy,  dissoluteness,  the 
evil  example  of  outrages,  or  bad  customs  in  families,  have  an  influ- 
ence in  determining  morbid  phenomena  that  in  many  cases  is  even 
stronger  than  heredity. 

The  emotional  natures,  the  litigious,  intolerant  dispositions  which 
explode  at  the  slightest  opposition,  impress,  by  example,  on  the 
growing  mind  of  the  child  or  youth  indelible  traces  of  morbosity, 
leaving  there  deep  sulci  which  gradually  become  channels  for  the 
current  of  all  the  mental  products  that  penetrate  from  the  environ- 
ment into  the  plasma  of  the  personality,  which  takes  on  an 
anomalous  development.  This  investigation  is  not  merely  a scien- 
tific display ; not  only  does  it  furnish  a sure  knowledge  concerning 
the  genesis  of  mental  affections,  but  it  has  at  the  same  time  an 
immediate  practical  value  : it  opens  up  to  the  alienist  physician 
paths  for  the  most  rational  therapeutic  indications.  What  curative 
and  educative  direction  shall  he  impress  on  a young  man  ? Where 
should  he  advise  him  to  live  and  be  educated  ? What  psycho- 
organic  vices  are  to  be  corrected  ? What  rudimentary  instincts  to 
be  developed  ? In  what  environment  is  he  to  be  placed  in  order 
to  bring  about  the  desired  result  in  a rational  manner  ? Therein 
lies  a series  of  practical  problems  ; but  it  is  well  not  to  anticipate 
here  what  we  have  to  expound  in  the  chapter  on  the  cure  and 
treatment  of  the  insane. 

The  inquiries  into  the  family  history  of  the  insane  or  psycho- 
pathic individual  are  pursued  in  a most  rigorous  and  complete 
manner.  The  reconstruction  of  the  genealogical  tree — trunk,  roots. 


4^2 


PSYCHIATRY 


and  branches — is  extremely  advantageous,  inasmuch  as  to  no 
function  is  there  more  frequently  transmitted  the  mark  and  charac- 
teristics of  the  progenitors  than  to  that  of  the  nervous  system. 
Many  coefficients  can  arrest  morbid  heredity,  rendering  it  latent,  or 
even  making  it  disappear,  but  this  happens  much  more  rarely  in  the 
case  of  morbidity  of  the  nervous  system  than  of  any  other  organ. 

The  individual  inherits  many  of  the  characteristics  of  his  parents 
and  ancestors  : the  tendencies,  the  instinct,  the  emotivity,  the 
intellectual  force  and  the  capacity  of  adaptation,  sociability,  special 
artistic  and  professional  aptitudes,  extravagances,  eccentricities, 
tics,  and  obsessions,  are  transmitted,  either  in  identical  or  in  different 
form.  Thus  we  come  to  know  what  morbid  features  belong  to 
the  individual,  and  what  he  has  inherited  from  his  family ; to  what 
extent,  if  any,  the  hereditary  blemish  has  been  aggravated  or 
mitigated,  and  for  what  reasons.  The  genealogical  tree  is  re- 
constructed at  least  up  to  the  great-grandparents  whenever  possible, 
and  should  include  collaterals  and  descendants.  It  is  well  known 
that  morbidity  of  the  nervous  system  may  remain  latent  in  an 
entire  generation,  and  present  itself  again  in  an  aggravated  degree 
in  the  next  ; but  if  proper  inquiry  be  made,  it  is  found  that  even  in 
these  cases  there  is  a certain  mental  weakness  in  the  parents  that 
escapes  superficial  analysis,  especially  of  ordinary  people. 

The  full  knowledge  we  now  have  of  these  matters  and  rich 
personal  experience  indicate  to  us  the  wide  limits  of  the  investiga- 
tion, inasmuch  as  it  cannot  be  confined  to  the  verification  of  the 
existence  of  an  ordinary  mental  affection  in  the  family,  but  includes 
also  nervous  affections  of  whatever  entity,  be  it  even  simple  neuras- 
thenia, so  common  at  the  present  day,  or  a circumscribed  neuritis, 
such  as  a facial  paralysis  a frigore.  The  notion  of  the  individual 
affection  must  be  integrated  in  those  of  the  family  affections,  and 
especially  of  the  family  character  ; just  as  there  are  families  immoral, 
litigious,  querulous,  emotional,  sexual,  so  there  are  those  in  which 
the  credulous,  the  acritical,  and  excessively  simple  abound.  The 
fact  is  that  excessive  meekness  of  mind  is  either  a form  of  imbe- 
cility or  borders  upon  it. 

At  other  times  we  come  across  families  composed  of  apparently 
intelligent  individuals  who  have  fallen  from  a high  social  position 
without  any  extrinsic  coefficient ; such  a decadence  is  often  due  to 
a deficiency  of  judgment,  to  credulit}^,  to  susceptibility  to  sugges- 
tion, to  defective  aptness  of  adaptation  in  conduct,  which  pro- 
claims a volitional  and  perceptive  defect.  Their  intelligence  is 
somewhat  aerial  and  superficial. 

Eccentricity,  drunkenness,  and  delinquency  are  investigated 
with  particular  care.  Eccentricity  possesses  a degenerative  signi- 
ficance equal  to  and  possibly  greater  than  insanity  (Maudsley, 
Morel,  Fere).  Drunkenness  either  is  itself  an  expression  of  mental 
weakness  or  of  disease,  such  as  dipsomania,  or  else  it  initiates  the 


METHODS  AND  FIELD  OF  CLINICAL  INQUIRY  413 


family  degeneration,  producing  the  gravest  forms  of  cerebropathy 
in  the  descendants  : infantile  eclampsia,  infantile  encephalitis, 
idiocy,  epilepsy  (Robinovitch,  Kowalewski,  and  others). 

Delinquency  is  in  itself  a good  indication  of  defect  or  functional 
anomaly  of  the  brain,  even  when  it  is  due  for  the  most  part  to  the 
environment  in  which  the  individual  has  been  brought  up  and 
developed.  From  this  point  of  view  (and  we  shall  make  it  clear 
in  the  respective  chapter)  it  should  be  noted  whether  the  family 
delinquency  is  due  to  the  social  surroundings  or  exclusively  to 
individual  factors  which  have  not  even  undergone  the  influence  of 
education. 

Consanguinity  in  marriage,  especially  between  neuropathic 
persons,  advanced  age  of  the  parents,  or  organic  weakness — con- 
stitutional or  resulting  from  disease — at  the  time  of  conception, 
may  likewise  be  causes  of  psychic  degeneration  and  of  morbidity 
in  the  offspring.  This  is  not  the  place  to  discuss  the  great  number 
of  hypotheses  at  the  present  day  concerning  the  manner  of  inter- 
preting heredity  and  its  laws,  nor  can  we  dilate  upon  the  fact  (well 
confirmed  since  the  time  when  Morel  clearly  demonstrated  it) 
that  very  often  the  hereditary  blemish  is  aggravated  in  the  suc- 
cessive generations,  nor  upon  the  reasons  for  which  it  sometimes 
becomes  neutralized,  at  least  temporarily,  by  the  intervention  of 
the  great  modifiers  of  the  nervous  system,  such  as  matrimony,  the 
physico-moral  environment,  education,  and  so  on. 

Here  we  must  content  ourselves  by  simply  stating  what  is 
already  well  known — viz.,  that  no  matter  what  the  anomaly  or 
deviation  from  the  anthropological  and  functional  type  of  the 
individual  or  family  with  respect  to  the  historical  moment  of  the 
existence  of  a society  or  a race,  it  may  be  the  first  link  of  a chain 
to  which  others  and  still  others  may  be  added  in  the  descendants, 
with  various  changes  up  to  the  gravest  forms  of  nervous  and  mental 
affections,  and  to  the  extinction  of  the  family. 

Having  completed  the  inquiries  into  the  intellectual  and  moral 
constitution  of  the  family,  it  is  necessary  to  become  acquainted 
with  the  history  of  the  individual,  retracing  his  earlier  years  and 
even  his  infancy.  It  is  not  only  useful  but  necessary  to  know  how 
the  maternal  gestation  proceeded  and  the  character  of  the  parturi- 
tion, since  severe  trouble,  mental  shocks,  infectious  diseases  during 
pregnancy — especially  scarlatina,  influenza,  small-pox,  and  enteric 
fever — falls,  injuries  on  the  abdomen,  as  also  difficult  parturition, 
prolonged  retention  of  the  foetal  head  in  the  pelvis,  misapplication 
of  the  forceps,  give  rise  to  cerebral  affections  or  to  morbid  cerebral 
tendencies  in  the  offspring  (Freud).  Such  morbid  tendency  is 
sometimes  well  manifested  for  a time  in  eclampsic  convulsions, 
which,  when  they  are  not  the  result  of  haemorrhages  or  inflamma- 
tions, are  an  expression  of  what  is  called  convulsibility,  and  of  what 


414 


PSYCHIATRY 


may'remain  latent  for  a long  time,  or  present  itself  again  in  maturity, 
in  any  vicissitude  of  life  whatsoever,  in  the  form  of  epilepsy,  or  any 
other  more  or  less  severe  mental  affection,  which  must,  to  all  appear- 
ance, be  connected  with  the  convulsions  suffered  by  the  child  in 
the  early  months  of  its  existence,  during  lactation,  dentition,  etc. 

The  epoch  of  the  development  of  language  and  of  walking  is , 
taken  into  special  consideration,  inasmuch  as  great  delay  signifies  | 
a true  weakness  and  evolutionary  deficiency  of  the  central  nervous 
system.  What  tendencies  did  the  child  manifest  in  assuming  its  ; 
first  relations  with  the  world,  what  instincts,  what  aptitudes,  what 
new  energies,  what  capacity  of  adaptation  to  the  family  or  school 
discipline,  what  perversions,  etc.  ? Above  all,  it  is  requisite  to  . 
inquire  at  what  period  and  in  what  manner  the  sexual  instinct  ; 
manifested  itself  ; e.g.,  I have  observed  remarkable  precocity  at 
the  age  of  three  years,  blind  impulsiveness  in  children  from  eight 
to  twelve  years,  and  sometimes  older,  leading  them  to  abandon 
themselves  to  onanism  or  to  bestial  acts,  without  any  awakening 
of  the  knowledge  of  danger.  This  I have  often  observed  among 
peasants  who  cohabit  with  domestic  animals. 

In  contrast  to  children  who  conform  to  the  educative  rules  of  : 
the  family  and  of  the  school,  and  who  assimilate  from  the  external  ! 
world  all  that  is  good  for  the  normal  evolution  of  their  understand-  ^ 
ing,  it  is  necessary  to  place  those  who  assimilate  little  or  nothing 
of  all  this,  and,  as  though  they  belonged  to  an  epoch  that  has  passed 
away,  or  to  a social  class  long  left  behind  by  their  parents,  are  . 
rebellious  or  refractory  to  any  means  of  education  whatsoever,  ; 
show  themselves  mobile  and  incoherent  in  conduct,  sometimes 
cruel,  irascible,  obstinate,  obtuse,  or  display  an  extraordinary  , 
intellectual  phosphorescence,  and  are  the  so-called  infant  prodigies,  = 
whose  future  in  many  cases  ends  in  complete  disappointment. 

Exaggerated  affectivity,  emotivity,  illogical  timidity,  cruelty  , 
to  animals,  are  all  indications  of  the  primitive  cerebral  structure,  ; 
over  which  education  and  time  sometimes  spread  the  fine  mantle  -i 
of  modernity,  whose  folds  the  storms  of  life  raise  now  and  again,  to 
reveal  to  a greater  or  less  extent  the  true  primitive  nature.  •; 

The  intellectual  capacity  of  the  child  and  the  youth,  and  the  j 
behaviour  in  school  should  be  objects  of  particular  inquiry,  because 
when  slow  and  compensatory  evolution  does  not  supervene  there  !: 
is  a connection  between  these  and  obtuseness  or  intellectual  in-  • 
capacity  of  the  adult,  a fact  which  explains  many  family  and  social  I 
phenomena  ; on  the  other  hand,  the  inquiry  furnishes  the  physician  j 
with  precise  indications  concerning  the  education  and  occupations,  || 
to  which  must  be  directed  a determined  form  or  a given  intellectual  I 
capacity.  | 

One  last  task  has  the  alienist  in  the  study  of  the  insane  or  anoma-  | 
lous  person,  and  that  is  the  investigation  of  the  social  environment  || 
in  w’hich  the  individual  has  developed  and  of  the  social  class  to  | 


METHODS  AND  FIELD  OF  CLINICAL  INQUIRY  415 


which  he  belongs,  because  too  often,  especially  amongst  Italians, 
do  we  find  that  betw^een  the  classes  and  the  masses  the  social  differ- 
ences are  great,  the  distance  enormous.  When  we  contrast  the 
impudently  trivial  conversation  of  the  women  of  the  masses,  even 
on  the  public  highway,  with  the  delicate  perfumery  of  the  thought, 
sentiment,  and  language  of  our  noble  dames ; the  shamelessness  of 
the  commonplace  woman  with  the  delicacy  of  speech  and  attitude 
of  the  polished  lady,  even  in  a graceful  error  in  conversation ; the 
threatening  and  sinister  bombastic  tirade  of  a plebeian  under  the 
influence  of  a supposed  injury  which  but  leaves  the  polished  and 
highly-developed  man  an  unruffled  calculator  of  the  value  to  be 
attached  to  the  offence,  and  a just  judge  of  what  best  means  he  must 
employ  to  neutralize  its  consequences,  it  is  easy  to  infer  that  in  an 
individual  belonging  to  polite  society  (since  the  differences  will 
exist)  such  triviality,  display,  and  vulgar  impulsiveness  serve  to 
show  up  all  the  more  strongly  the  long  path  traversed  by  the  most 
polished  and  the  retrograde  significance  of  those  facts  in  the  evolved 
class  (degeneration) ; while  in  the  plebeian,  although  they  are  cer- 
tainly teratological  phenomena  with  respect  to  the  conception  we 
have  formed  of  polite  society,  they  are  destitute  of  any  morbid 
significance.  If  a lady  enters  a shop  and  steals  some  article,  or 
a doctor  entertained  at  the  house  of  a relative  appropriates  some 
coffee  or  sugar,  the  fact  alone  that  these  two  belong  to  a social 
grade  in  which  these  acts  are  censured  may  indicate  morbosity 
on  their  side ; but  if  a plebeian  woman  or  child  who  is  being  reared 
in  an  environment  where  theft  is  held  to  be  a legitimate  means  of 
subsistence,  where  the  germ  of  respect  for  the  property  of  others 
has  not  yet  been  cultivated,  where  the  father  gives  the  example 
and  the  advice  to  steal,  takes  to  pocket-picking,  the  phenomenon 
no  longer  falls  under  the  dominion  of  psychiatry. 

The  examination  of  the  individual  who  is  insane,  or  who  is  sup- 
posed to  be  so,  is,  accordingly,  the  most  difficult  task  which  modern 
medicine  has  assigned  to  the  intelligence  and  culture  of  the  practical 
physician,  in  whose  mode  of  examination  there  are  no  tolerable 
transitions  as  regards  either  method  or  extent  of  investigation. 


CHAPTER  II 


CLASSIFICATION  OF  THE  MENTAL  AFFECTIONS 

Before  commencing  the  exposition  of  the  forms  that  the  psycho- 
pathies assume,  it  is  well  to  come  to  an  understanding  about  their 
classification.  At  the  outset  I had  resolved,  much  against  my  will, 
not  to  present  any  classification  in  this  treatise,  consistently  with 
the  method  followed  in  my  school  for  many  years.  It  was  not  that 
I was  less  alive  than  many  of  my  contemporaries  and  predecessors 
to  the  need  of  a classification,  of  a categorization,  which  we  feel 
imperative  through  that  associative  power  intrinsic  in  things,  just 
as  in  the  products  of  our  thought ; but  I felt  a strong  repugnance  for 
a work  which  I deemed,  and  still  deem,  almost  useless,  as  giving 
only  what  is  incomplete,  and  therefore  not  very  vital. 

We  have  had  presented  to  us  such  a large  number  of  classifica- 
tions that  our  faith  in  another  is  shaken  beforehand.  The  modifica- 
tions wrought  by  authors  on  pre-existing  classifications  have  not 
always  been  the  necessary  effect  of  progress  in  the  knowledge  of 
mental  affections  and  their  differentiation,  but  principally  of  sub- 
jective views,  inasmuch  as  the  argument  is  polyhedric,  and  no 
matter  how  we  study  or  examine  it,  there  is  always  some  aspect 
that  escapes  observation,  whilst  others,  at  different  times,  fall  into 
the  field  of  inquiry.  As  a sphere  with  various  designs,  made  to 
revolve  on  different  axes,  presents  a new  aspect  at  every  turn,  sa 
the  field  of  the  mental  affections  presents  a different  picture  on  each 
attempt  at  classification. 

Of  the  mental  affections,  the  facts  that  are  most  abundant,  best 
won  to  the  science,  most  rationally  classified,  are  the  nosographic. 
But  an  exclusively  nosographic  classification  is  so  empirical  that  it 
fails  to  satisfy  even  the  less  pressing  exigencies  of  a democratization 
of  the  science,  which  thereby  ends  in  losing  its  dignity  and  physi- 
ognomy. On  the  other  hand,  it  is  to  be  noted  that  the  advantage 
of  a nosographic  classification  would  be  very  disputable  even  were 
it  not  overcome  by  the  confusion  that  would  thereby  result  in  the 
intrinsic  knowledge  of  the  nature  of  the  mental  affections. 

A simple  nosographic  classification  would  be  a source  of  scientific 

416 


CLASSIFICA  TION  OF  THE  MENTA  L AFFECTIONS  417 


misconceptions  ; the  symptomatology  cannot  be  singled  out  from 
other  factors.  It  is  well,  however,  to  note  that  two  factors  never 
coincide.  The  lines  are  not  superimposed  ; the  designs  do  not 
correspond.  From  whatever  side  we  consider  the  mental  affections 
with  the  object  of  classifying  them,  we  arrive  at  fictitious  associa- 
tions, which  express  only  one  part  of  the  truth,  one  or  more  contacts, 
not  all. 

The  two  criteria  in  the  formation  of  a scientific  classification 
which  have  been  so  happily  employed  in  general  medicine  would, 
if  adopted  in  psychiatry,  give  a very  inferior  and  confusing  result. 

I allude  to  the  aetiological  and  a.natomo-pathological  criteria. 
We  do  not  know  why  tubercular  infection  produces  in  one  pre- 
disposed individual  neuritis,  in  another  melancholia,  in  another 
the  positive  certainty  to  recover  from  the  affection  and  to  enjoy 
life  ; nor  do  we  know  why  hereditary  syphilis  in  one  predisposed 
person  gives  rise  to  idiocy,  in  another  to  hereditary  tabes,  in  another 
to  infantile  spastic  hemiplegia ; why  the  tubercle  bacillus  gives  rise 
to  tuberculosis,  the  comma  bacillus  to  cholera,  the  streptococcus 
aureus  to  pyaemia,  the  pneumococcus  to  croupous  pneumonia, 
and  the  bacillus  of  Eberth-Gaffky  to  enteric  fever.  Many  of  these 
micro-organisms  produce  confusedly,  melancholia,  sensory  delirium, 
stupor,  or  polyneuritis,  along  with  the  polyneuritic  psychosis. 
The  post-infiuenzal  and  the  post-enteric  psychoses  present  very 
different  nosographic  features,  although  there  may  be  reason 
to  suppose  that  they  are  produced  by  the  same  agent.  On  the 
other  hand,  the  puerperal,  the  post-influenzal,  and  some  gestational 
psychoses  may  bear  so  close  a resemblance  in  their  clinical  aspect 
and  their  course  (when  one  has  had  a large  field  of  observation) 
as  at  once  to  give  rise  to  the  belief  that  different  causes  may  give 
rise  to  identical  syndromes,  and  mental  affections  of  different 
clinical  figure  may  be  generated  by  the  same  cause.  It  is  useless 
to  multiply  the  examples.  An  aetiological  classification,  now  that 
we  know  that  injuries  and  all  the  endogenous  and  exogenous  toxic 
products  give  rise  to  the  most  varied  syndromes  by  the  intervention 
of  another  great  factor — the  individual — which  itself  turns  the 
great  wheel  of  the  nosological  varieties,  would  be  neither  scientific, 
rational,  nor  useful. 

The  same  individual  factor  gives  us  the  variety,  which  by  some 
authorities  has  been  considered  on  a basis  of  aetiological  classifica- 
tion with  respect  to  the  various  epochs  of  life.  What  interest,  in 
fact,  can  that  distinction  have  for  pathology  that  takes  its  name 
from  puberty,  from  the  puerperium,  or  from  the  menopause  ? When 
the  fundamental  symptoms  of  disease  are  met  with  identically  in 
the  pubescent,  the  adult,  or  the  puerperal  individual,  the  affection 
is  necessarily  the  same  in  its  fundamental  mechanism,  save  that 
the  variety  of  the  tout  ensemble  of  the  clinical  figure  arises  from 
the  psychological  variety  of  the  incompleted  personality  of  the 

27 


4i8 


PSYCHIATRY 


pubescent  or  the  adolescent  as  compared  with  that  of  the  adult 
person,  or  from  the  special  condition  of  the  puerperal  woman,  whose 
consciousness  is  filled  with  images  that  cannot  have  any  place  in 
that  of  the  man  or  the  youth  at  the  opening  of  the  flower  of 
sexuality. 

Not  even  is  a classification  on  an  anatomo-pathological  basis 
to  be  taken  seriously.  I fully  appreciate  the  fact  that  it  might 
and  ought  to  be  our  ideal.  General  medicine  has  given  an  example 
of  its  good  fortune,  when  it  constructed  the  indestructible  arches 
of  pathological  anatomy,  on  which  it  has  erected  the  great  and 
magnificent  edifice  of  pathology  and  classification.  But  where 
is  the  anatomo-pathological  basis  in  psychiatry  ? What  will  be 
the  anatomo-pathological  alteration  of  the  brain  in  hysterical 
stupor  which  sometimes  disappears  in  a very  short  time,  merely 
as  we  succeed  in  dissipating  the  anaesthesia  and  analgesia  of  the 
whole  or  a great  part  of  the  body  ? What  is  the  anatomical  sub- 
stratum of  the  somnambulic  states,  induced  or  spontaneous,  which 
may  be  made  to  disappear  in  an  instant  ? What  is  that  of  paranoia, 
of  eccentricity  (paraphrenia),  and  of  emotional  impressionability 
whose  last  degrees  become  fused  in  the  syndrome  of  fixed,  coercive 
ideas,  etc.  ? And  what  rule  can  we  draw  from  our  knowledge  of 
the  psychic  disturbances  consequent  upon  destructive  processes 
in  the  brain,  if  the  respective  syndromes  depend  upon  the  seat 
and  extent  and  not  upon  the  nature  of  the  focus  ? 

There  is  a syndrome,  terminal  to  destructive  foci  in  the  brain, 
which  has  been  described  as  post-hemiplegic  dementia  ; but  every- 
one knows  that  a destructive  focus  in  the  temporal  lobe  gives  a 
syndrome  quite  different  from  that  arising  from  a destructive 
process  in  the  somaesthetic  zone  ; a lesion  of  the  occipital  lobe  gives 
a syndrome  quite  different  from  that  given  by  a focus  in  the  pre- 
frontal region  ; lesions  of  the  right  hemisphere  produce  mental 
disturbances  rather  less  significant  than  those  consecutive  to  lesions 
of  the  left  hemisphere.  In  the  outward  manifestation  that  reflects 
the  extent  of  the  focus,  difference  of  topography  is  a factor  of  the 
greatest  importance.  A small  focus  in  the  first  temporal  con- 
volution on  the  left  side  may  give  rise  to  a syndrome  with  prevailing 
notes  of  dementia,  while  a focus  in  the  frontal  lobe,  either  right  or 
left,  may  pass  ali;)iost  unobserved. 

The  minute  alterations  in  the  cells  observed  up  till  now  do  not 
present  anything  characteristic  of  each  psychopathic  form.  Chro- 
matolysis (cytolysis),  which  is  met  with  in  sensory  delirium,  is  found 
also  in  profound  melancholia,  and  possibly  this  alteration  does  not 
differ  essentially,  so  far,  at  least,  as  we  can  deduce  from  the  re- 
searches thus  far  prosecuted,  from  the  cytolysis  resulting  from 
ura.miic  intoxication,  or  from  that  depending  on  the  isolation  of 
the  nerve-cell  from  its  associations.  Again,  the  lesions  that  are 
met  with  in  secondary  dementia  are  not  capable  of  differentiation, 


CLASSIFICA  TION-  OF  THE  MENTAL  AFFECTIONS  419 


no  matter  what  the  form  of  the  dementia  and  the  primary  affection 
to  which  it  was  the  sequel. 

It  is  needless,  however,  to  multiply  instances,  or  to  proceed 
any  further  in  this  demonstration.  From  the  few  facts  already 
put  forward,  it  appears  evident  to  everyone  interested  in  medical 
instruction  that  a classification  of  the  mental  affections  on  an 
anatomo-pathological  basis  is  to-day  still  out  of  the  question. 
Our  tendency  to  find  an  anatomo-pathological  basis  is  determined, 
and,  indeed,  justified,  by  our  scientific  education,  and  by  the  trend 
of  general  medicine  ; it  is  no  more  than  an  aspiration,  but  it  is 
efficacious  in  promoting  the  progress  of  our  science.  Perhaps  what 
we  call  the  individual  factor  corresponds  to  the  teratological  or 
anatomo-pathological  particularity  of  the  nervous  elements,  con- 
sidered singly  or  in  their  more  or  less  wide  associations  : it  is  the 
field  the  most  promising  of  good  fruits  for  the  investigators  of  the 
future  ; but  meanwhile,  if  the  state  of  our  knowledge  justifies  the 
aspiration,  it  does  not  justify  the  attempt.  We  must  take  some 
other  course. 

For  the  same  reasons,  we  have  not  found  preferable  the  psycho- 
logical criterion  in  the  sense  of  Ziehen,  followed  in  this  conception 
also  by  Mendel  in  his  last  handbook  of  psychiatry.  Mendel  dis- 
tinguishes the  intellectual  from  the  affective  psychoses,  inasmuch 
as  the  latter  are  not  accompanied  by  true  intellectual  defects, 
while  in  the  former  the  intellectual  defect  or  disturbance  is  the  most 
conspicuous  fact  of  the  affection. 

Such  a distinction,  however,  is  founded  more  on  appearance 
than  on  reality,  because,  although  the  affective  psychoses,  such  as 
mania  and  melancholia,  appear  to  be  essentially  affections  of  the 
emotions  and  the  sentiments,  the  accompanying  intellectual  dis- 
turbance is  equally  profound  and  substantial,  while  in  the  intel- 
lectual psychoses  such  as  stupor  the  vitality  of  the  emotions  and 
of  the  sentiments  is  also  abolished  or  profoundly  disturbed ; and 
paranoia,  as  we  shall  see,  is  essentially  an  affective-intellectual 
disorder,  inasmuch  as  the  deliria  arise  from  an  abnormal  manner  of  ^ 
feeling.  The  psychological  criterion,  accordingly,  is  no  less  exempt 
from  criticism  than  the  other  two — the  aetiological  and  the  anatomo- 
pathological.  It  also  must  be  put  to  one  side. 

The  setiological  criterion,  harmonized  with  the  symptomato- 
logical,  has  met  with  better  fortune,  and  rightly  so.  The  classifica- 
tions of  Krafft-Ebing  and  of  Schiile,  received  with  much  favour  in 
Germany,  and  dominant  there  and  elsewhere  for  a long  time,  have 
been  mainly  inspired  by  it.  One  important  feature  I find  in  the 
classification  adopted  by  these  two  prominent  psychiatrists  : it 
IS  that  which  refers  to  the  grade  of  evolution  of  the  brain  and 
of  the  mind,  and  gives  material  for  one  great  primary  division 
into  psychoses  on  a foundation  of  complete  psycho-organic 
development,  and  psychoses  on  a foundation  of  defective  or 

27 — 2 


420 


PSYCHIATRY 


incomplete  development.  Therein  the  primary  happy  conception 
of  Morel  finds  a large  application,  and,  as  we  shall  see,  it  is  also 
the  criterion  that  gives  form  to  the  classification  preferred  by  me. 

In  Italy  the  problem  of  the  mental  affections  has  been  dealt  with 
from  the  very  infancy,  we  might  say,  of  psychiatry,  and  the  progress 
of  the  evolution  of  Italian  psychiatric  thought  has  been  mapped  out 
into  stages  by  the  proposals  and  discussions  in  the  congresses  of  the 
learned  societies,  more  especially  of  the  psychiatric,  from  1845  up 
till  the  last  congress  of  Italian  psychiatrists  held  recently  in  Ancona. 

The  nature  of  this  treatise  does  not  permit  of  a 'report  of  the 
principal  and  most  recent  classifications  proposed  by  the  Italian 
psychiatrists  (Morselli,  Angiolella,  D’Agostini),  nor  of  a compara- 
tive examination  of  these  classifications  and  those  of  Krafft-Ebing 
and  of  Schlile — the  foreign  psychiatrists  whose  names  rank  amongst 
those  best  known  in  Italy  by  the  diffusion  of  their  treatises  translated 
into  Italian — those  of  the  English  writers  Berkeley  and  Clauston, 
and  many  others  from  all  countries.  They  demonstrate  more 
particularly  the  great  progress  of  psychiatric  thought,  as  compared 
with  the  old  classification  of  Verga,  and  at  the  same  time  the 
eclecticism  of  Italy,  where  originality,  by  no  means  rare,  is  not 
disjoined  from  the  utilization  of  all  that  is  good  and  assimilable  in 
the  foreign  productions. 

While  Morselli  pays  much  attention  to  the  clinical  and  psycho- 
logical aspect  of  the  mental  affections,  D’Agostini  and  Angiolella 
have  introduced  into  their  classification  the  more  recent  conception 
of  the  intoxications  and  the  consequent  histological  alterations, 
criteria  which,  if  they  cannot  and  must  not  be  lost  sight  of  for  a 
more  rational  categorization  of  the  mental  affections  in  the  future,  ’ 
cannot  furnish  in  the  actual  evolutionary  grade  of  our  sciences  a ' 
sure  foundation  for  a rational  and  more  lasting  classification.  | 

In  the  last  congress  at  Ancona  the  expositive  and  critical  work 
of  De  Sanctis  was  of  no  avail  in  giving  a classification  which  should  : 
be  the  synthetic  expression  of  modern  psychiatric  thought.  t 

The  members  of  the  commission  appointed  with  the  object  of  • 
giving  to  Italy  a more  rational  and  scientific  classification  than  ' 
that  used  for  the  official  statistics  up  till  that  time  did  not  ] 
succeed  in  coming  to  an  agreement ; their  good  intentions  failed  in  ' 
the  face  of  insurmountable  intrinsic  difficulties.  I 

Fresh  obstacles  arose  every  moment  under  the  lash  of  criticism,  ' 
and,  wrote  the  reporter,  all  had  to  abandon  their  own  individual  i 
convictions,  or  many  of  them,  and  arrive  at  a common  field  of  'I 
view,  so  as  to  construct  a classification  which  should  correspond  on  ji 
the  one  hand  to  the  thought  of  modern  psychiatrists,  and  on  the 
otlier  to  the  necessity  for  a formulary  which  all  might  adopt  so  as  | 
to  come  to  a common  understanding,  possibly  with  the  single  |j 
object  of  furnishing  the  elements  for  general  statistics  of  the  mental  | 
affections.  ^ 


CLASSIFICATION  OF  THE  MENTAL  AFFECTIONS  421 


The  following  classification  is  exactly  the  one  proposed  by  the 
commission  and  approved  by  the  congress.  I am  pleased  to  repro- 
duce it  here. 

1.  Congenital  Psychoses  : 

Arrests  and  deviations  of  psychic  development. 

Phrenasthenia. 

Moral  insanity. 

Psychopathia  sexualis. 

2.  Simple  Acute  Psychoses  : 

States  of  mania. 

States  of  melancholia. 

Amentia. 

Sensory  psychosis. 

3.  Chronic  Psychoses,  Primary  and  Consecutivi'.  * 

Paranoia. 

Periodic  psychoses. 

States  of  dementia  : 

{a)  Senile. 

(b)  Secondary. 

4.  Paralytic  Psychoses  : 

Classic  paralytic  dementia. 

Luetic  dementia. 

Alcoholic  dementia. 

Encephalomalacic  dementia. 

5.  Psychoses  from  Neuroses  : 

Epileptic  psychosis. 

Hysteric  psychosis. 

Neurasthenic  psychosis. 

Choreic  psychosis. 

5.  Toxic  Psychoses  : 

Pellagrous  psychosis. 

Alcoholic  psychosis. 

Morphinic  psychosis. 

Cocainic,  etc.,  psychosis. 

7.  Infective  Psychoses  : 

Post-influenzal,  enteric,  etc.,  psychosis. 

Syphilitic  psychosis- 
Acute  delirium. 

In  this  treatise  I do  not  feel  bound  to  adapt  myself  in 
any  way,  because  no  extraneous  reason  can  constrain,  by  any 
directive,  scientific  thought  that  arises  from  long  observation. 


422 


PSYCHIATRY 


Although  for  a long  time  I have  believed  in  the  theoretical  futility 
of  a classification,  nevertheless,  for  the  reasons  given,  I have  adopted 
one,  which  is  also  very  eclectic  in  the  sense  that  it  is  inspired  by 
nosological,  setiological,  and  anatomo-pathological  criteria. 

Having  now  recognized  generally  the  impossibility  of  holding  to  a 
single  criterion,  it  is  clear,  as  the  most  recent  attempts  demonstrate, 
that  that  classification  gives  promise  of  wider  acceptation  and  longer 
duration  which  assumes  the  greatest  number  of  fundamental  criteria 
on  which  is  based  the  general  knowledge  concerning  the  genesis 
and  nature  of  the  mental  affections. 

Such  has  been  the  directive  thought  in  this  other  attempt  at 
classification. 

The  mental  affections  may  be  divided  into  three  great  groups. 
The  first  comprises  the  affections  represented  essentially  by  an 
evolutionary  psycho-cerebral  defect ; a second  group  comprises  all 
the  mental  affections  of  infective,  autotoxic,  and  toxic  origin 
developing  in  individuals  regularly  evolved  ; in  the  third  group 
are  included  all  the  affections  with  an  organic  substratum,  localized 
or  diffuse,  in  the  central  organ  of  mind. 

These  groups  are  not  separated  and  precisely  distinguished 
from  one  another,  because,  each  of  them  being  distinguished  by  a 
characteristic  not  comparable  with  that  which  contradistinguishes 
the  other  two,  it  is  very  evident  that  the  characteristics  not  included  * 
under  the  differential  criteria  are  common  to  all  or  some  of  the 
groups. 

It  is  clear  that  the  intoxications  and  the  infections,  besides 
finding  a good  soil  for  development  in  brains  predisposed  but  fully 
evolved,  secure  favourable  conditions  also  in  the  brains  of  the  first 
group  ; and,  on  the  other  hand,  the  evolutionary  defects  of  the  brain 
are  very  often  determined  by  anatomo-pathological  lesions,  either 
diffuse  and  incapable  of  localization — e.g.,  hydrocephalus — or 
circumscribed — like  encephalitis,  destructive  foci,  localized  cerebral 
syphilids,  and  agenesias — lesions  which  often  occur  during  gestation 
or  in  the  early  years  of  extra-uterine  life. 

We  can  with  good  reason  hold  that  localized  lesions  which  are  a 
cause  of  arrest  of  cerebral  development,  or  of  tardy  and  imperfect 
development,  may  also  be  of  infective  origin,  and  that  some 
infections,  such  as  syphilis  and  variola,  or  some  intoxications,  like 
that  resulting  from  the  imbibition  of  alcoholic  stimulants  in  toxic 
quantities  by  the  mother  or  father,  have  a great  influence  on  the 
evolutionary  potentiality  of  the  individual,  and  for  the  present  we 
may  say  that  it  is  immaterial  whether  the  cause  has  its  seat  in  the 
ovum  or  in  the  poisoned  nemasperm  (Maffucci,  Fere).  We  may  also 
hold  that  the  second  group  of  mental  affections  arising  from  intoxi- 
cation and  infection  is  probably  based  on  anatomical  alterations, 
inasmuch  as  we  know  that  endogenous  or  exogenous  toxins  produce 
microscopic  alterations  in  the  minute  structure  of  the  nerve-elements 


CLASSIFICATION  OF  THE  MENTAL  AFFECTIONS  423 


(chromatolysis  or  cytolysis).  The  infections  and  intoxications, 
then,  are  not  confined  to  the  second  group,  but  are  found  also  in  the 
first  and  probably  in  the  third  ; and  the  anatomical  lesions  are  not 
characteristic  of  the  third  group  alone,  but  are  found,  and  that  to  a 
marked  extent,  in  the  first  and  in  the  second.  It  is  clear,  however, 
that  the  differential  exponent  of  the  single  groups  is  the  predominant 
characteristic  in  each  of  them,  to  which,  no  matter  what  be  the 
clinical  picture,  it  gives  the  specific  note  of  recognition,  while,  on  the 
other  hand,  it  permits  a more  certain  pathological  orientation  and  a 
more  logical  distributign  of  the  psychopathic  syndromes. 

In  putting  forward  in  this  manner  the  scientific  material  con- 
stituting the  patrimony  of  psychiatry,  we  have  never  lost  sight  of  the 
clinical  criterion  in  the  widest  sense  of  the  word — a criterion  which 
has  been  adopted  by  Kraepelin  very  explicitly  in  the  last  edition  of 
his  work,  and  which  must  be  conceived  in  the  sense  of  the  complete 
knowledge  of  the  illness,  its  evolutionary  story,  and  the  different 
attitudes  it  may  assume  at  different  times. 

It  was  this  that  permitted  me  to  comprise  under  the  denomination 
of  ‘ sensory  insanity  ’ several  of  those  syndromes  which  were  and 
are  still  designated  as  distinct  maladies  by  the  French  and  German 
psychiatrists — such  as  mental  confusion,  amentia,  acute  dementia, 
stupor,  katatonia,  etc. 

I have  a rooted  conviction  that  many  mental  affections  bearing 
a great  name  and  occupying  a distinct  place  in  the  classifications 
are  only  prolonged  phases  of  one  affection  whose  initiation,  as 
frequently  happens,  has  completely  escaped  observation.  Granted 
even  that  the  rationality  of  the  division  of  all  the  mental  affections 
into  the  three  groups  before  mentioned  becomes  recognized  by 
psychiatrists,  another  great  difficulty  presents  itself  in  the  distribu- 
tion of  the  mental  affections  for  each  single  group. 

In  this  regard  the  group  best  definable  is  the  third,  which 
corresponds  to  the  fourth  group  of  the  classification  proposed 
by  the  commission  at  the  congress  at  Ancona,  to  which  should  be 
added  the  subgroup  of  the  traumatic  psychoses,  inasmuch  as 
the  grosser  anatomical  lesion,  though  probable,  may  not  be  capable 
of  verification. 

Much  greater  difficulties  are  met  with  in  the  attempt  to  fix  the 
limits  of  the  first  group,  as  several  affections  can  belong  to  the  first 
as  well  as  the  second  group,  according  to  the  side  from  which  they 
are  viewed.  Where  shall  we  place  epilepsy,  hysteria,  fixed  ideas, 
late  paranoia,  and  some  other  states  ? The  common  view  to-day  is 
that  epilepsy  is  of  toxic  origin  ; that  hysteria  sometimes  develops 
in  beings  well  constituted  cerebrally  ; that  fixed  ideas  sometimes 
present  themselves  for  a time  as  stigmata  of  cerebral  imperfection, 
at  other  times  appear  at  a late  period  in  well-constituted  persons 
worn  out  either  by  overwork  or  by  the  abuses  of  life.  Unprejudiced 
and  close  observation  of  the  facts,  however,  permits  us  to  arrive  at 


424 


PSYCHIATRY 


a sufficiently  logical  and  well-founded  distinction  of  all  these  morbid 
forms.  Since  we  cannot  here  take  account  of  that  occasional 
epilepsy  that  is  symptomatic  of  such  processes  as  traumata,  en- 
cephalitis, tumours,  syphilitic  endarteritis  and  atheroma,  etc.,  the 
majority  of  the  epilepsies,  with  these  exceptions,  are  more  or  less 
early  manifestations  of  a defective  cerebral  evolution. 

The  epileptic  convulsions  of  adolescents  or  youths  who  have  the 
appearance  of  a normal  intellectual  development  are  allied  in  the 
majority  of  instances  to  eclampsia,  which,  after  all,  is  nothing  else 
than  the  epilepsy  of  infancy.  It  is  always  an  expression  of  more  or 
less  sensible  cerebral  anomalies — cerebral  morbidity,  asymmetries, 
anomalies  of  the  intimate  structure,  etc. — while,  on  the  other  hand,  it 
leaves  indelible  stigmata  of  its  temporary  existence  in  the  excitable, 
irascible,  violent,  impulsive  character.  The  search  for  these  notes 
in  epileptics  with  a well-attained  and  sometimes  even  luxuriant 
intellectual  evolution  is  almost  always  positive  : their  presence  is 
the  irrefutable  proof  of  an  evolutionary  defect  of  the  mind  with 
regard  to  those  activities  and  manifestations  which  are  the  highest 
and  surest  expression  of  a high  mental  development,  summed  up  in 
the  attentive  power,  in  the  ready  and  happy  utilization  of  all  the 
intellectual  resources,  and,  above  all  else,  in  the  sure  control  and 
command  of  the  passions.  It  is  clear  that  this  form  of  epilepsy — 
which  I would  almost  call  primary,  and  which  should  be  included  in 
the  first  group — cannot  be  confused  with  that  form  symptomatic 
of  the  most' diverse  processes  to  which  the  brain  may  be  subject. 

We  are  well  aware,  however,  that  while  the  epilepsy  is  frequently 
latent,  in  its  psychic  character  it  exists  concealed  by  intelligence  of 
no  mean  order,  and  we  erroneously  suppose  that  we  are  dealing  with 
an  acquired  form,  while,  on  the  contrary,  as  I have  already  said,  the 
convulsions  are  connected,  through  the  conducting  wires  of  the 
character,  with  the  epilepsy  of  infancy,  and  may  be  considered  as 
evident  in  the  insufficiency  of  the  highest  mental  powers. 

Even  hysteria  may  be  comprised  in  the  first  group.  The  well- 
evolved  mind  carries  with  it  the  character  of  strong  organization 
and  resistance  to  disintegrating  agents.  If  we  assume  that  the 
fundamental  character  of  hysteria  is  decomposability  of  the  psychic 
personality  (imitativeness,  suggestiveness,  credulity,  mobility,  etc.), 
we  must  classify  hysteria  among  the  defects. 

No  one  will  contest  the  complete  curability  of  hysteria,  even 
when  it  assumes  the  gravest  form,  yet,  on  the  other  hand,  no  one 
who  has  had  opportunities  of  long  and  close  observation  can  deny 
the  latency  of  hysteria  in  the  psychic  character,  either  after  recovery 
or  even  when  the  disease  has  never  shown  all  the  features  character- 
istic of  the  minor  or  the  major  affection. 

We  may,  without  fear  of  contradiction,  enumerate  among 
evolutionary  defects  fixed  ideas,  which  hold  to  another  fundamental 
law  of  the  mind — viz.,  that  of  the  prompt  renewal  of  impressions. 


CLASSIFICATION  OF  THE  MENTAL  AFFECTIONS  425 


the  prompt  elimination  from  the  consciousness  of  all  the  useless 
perceptions  or  products  of  the  mind,  and  the  presence  of  an  emo- 
tional exponent  not  exceeding  a certain  limit  compatible  with  the 
intensity,  duration,  and  nature  of  the  agents. 

If  the  emotivity  is  exaggerated — and,  as  a rule,  it  is  also  of  a 
primitive,  unevolved  nature — if  the  eliminating  power  of  the  con- 
sciousness is  low  or  almost  nil,  if  the  residuum  or  the  trace  of  the 
impression  is  exceptionally  strong  and  prolonged,  besides  being 
disproportionate  to  the  intensity  and  nature  of  the  stimulus,  all 
this  is  a psycho-cerebral  evolutionary  defect.  Such  an  impression- 
ability may  be  traced  in  all  individuals  in  whom  we  have  reason 
to  believe  the  existence  of  an  acquired  form  of  fixed  ideas  through 
superadded  neurasthenia,  which  in  most  cases  is  constitutional  and 
latent,  and  it  is  therefore,  in  my  opinion,  to  be  included  in  the 
group  of  the  evolutionary  defects. 

The  inquiry  into  the  origin  of  the  morbid  phenomena  of  the 
mind  and  the  investigation  of  the  individual  and  family  character 
of  the  patient  furnish  elements  for  a clearer  knowledge  of  the 
phenomena  and  the  syndromes,  hence  for  a more  rational  classifica- 
tion of  the  mental  affections . Having  regard  to  these  considerations, 
the  first  great  group  appears  constituted  as  follows  : 

1.  Phrenasthenias. 

2.  Paraphrenias. 

3.  Congenital  moral  insanity. 

4.  Epilepsy. 

5.  Hysteria. 

6.  Developmental  paranoia. 

7.  Fixed  ideas — emotivity. 

8.  Developmental  neurasthenia. 

9.  Sexual  psychopathies. 

The  second  group  should  comprise  all  those  psychopathies  that 
arise  in  individuals  with  normally  evolved  brain.  It  is  not  exclusive, 
since  the  incompletely  evolved  are  likewise  subject  to  the  disorders 
in  this  group ; but  this  does  not  diminish  the  value  of  certain  facts 
that  concur  in  impressing  on  the  group  in  question  the  essentially 
characteristic  features  that  distinguish  it  from  the  other  two — 
viz.,  (i)  taking  into  account  the  distances  between  the  limits  that 
mark  the  grade  of  psycho-somatic  evolution  in  each  race,  the 
affections  constituting  the  group  arise  in  most  instances  in  indi- 
viduals certainly  predisposed  yet  normally  evolved  ; (2)  their 
commencement  is  acute  ; (3)  it  is  always  an  extraneous  product, 
biochemical  or  otherwise,  endogenous  or  exogenous,  that  induces 
the  histological  and  chemical  alterations  in  the  nerve-element, 
whence  arise  various  clinical  pictures  which  precisely  enter  into  the 
constitution  of  this  group,  further  divided  into  two  subgroups  : 

(a)  Psychoses  arising  from  infections  and  auto-intoxications. 

{h)  Toxic  psychoses. 


426 


PSYCHIATRY 


In  the  first  subgroup  we  include  : 

Mania. 

Lypemania. 

Exalted-depressive  insanity. 

Circular  and  periodical  insanity. 

Sensory  insanity. 

Mental  confusion. 

Acute  paranoia. 

Late  paranoia. 

Neurasthenic  insanity. 

Choreic  insanity. 

Luetic  insanity. 

Acute  delirium. 

In  the  second  subgroup  we  include  : 

Pellagrous  insanity. 

Alcoholic  ,, 

Morphinic  ,, 

Cocainic  ,, 

Chloralic  ,, 

Saturnine  ,, 

Insanity  from  carbon  monoxide. 

Anyone  may  educe  from  this  grouping  that  if  I have  made  no 
mention  of  amentia,  acute  dementia,  katatonic  psychosis,  dementia 
praecox,  it  is  because  the  objective  and  historical  examination  of 
these  conditions  must  convince  every  sincere  observer  that  they 
are  only  syndromes,  sometimes  simple  phases  or  gradations  of  the 
same  sensory  psychosis  ; for,  according  to  my  long  experience,  there 
is  always  a preceding  hallucinatory  state  which  should  characterize 
the  true  nature  of  the  malady,  and  oblige  us  to  recognize  those 
syndromes  as  not  really  distinct  morbid  forms,  but  phases  and 

varieties  of  an  identical  affection.  In  fact,  it  is  by  no  means  a rare 

thing  for  sensory  insanity  to  pass,  during  the  long  course  of  the 
illness,  through  the  different  phases  in  which  is  successively 
summed  up  the  figures  of  amentia,  acute  dementia,  katatonia. 

On  the  other  hand,  I have  added  to  the  group  acute  paranoia 
and  confusion.  The  first,  though  very  rare,  is  sharply  distinguished 
from  hallucinatory  mental  confusion,  as  I have  had  occasion 'to 
observe  in  my  wide  experience.  It  is  an  acute  disturbance  re- 
sembling sensory  insanity,  but  having  only  the  appearance  of  it, 
being  in  reality  a disturbance  exclusively  in  the  field  of  the  intellect, 
and  consisting  essentially  in  a false  interpretation  of  real  percep- 
tions of  the  external  world.  I have  admitted  into  the  same  group 
mental  confusion,  although  I am  convinced  that  it  always  follows 
hallucinations,  because  in  some  very  rare  cases  I have  not  succeeded 
in  confirming  the  existence  of  sensory  disturbances  whilst  recon- 


CLASSIFICATION  OF  THE  MENTAL  AFFECTIONS  427 

structing  the  history  of  the  illness,  and  therefore  I cannot,  with 
due  respect  to  the  observations  of  Chaslin  and  others,  exclude  the 
possibility  of  the  existence  of  a form  of  confusion  not  hallucinatory. 

The  third  group  comprises  all  those  affections  and  syndromes 
which  are  the  expression  of  known  and  demonstrable  anatomo- 
pathological  alterations  of  the  brain  : 

Paralytic  dementia. 

Luetic  dementia. 

Senile  dementia. 

Post-hemiplegic  dementia. 

Aphasic  dementia. 

Traumatic  dementia. 

Dementia  arising  from  tumours,  scleroses,  plaques,  and 
other  organic  diseases  of  the  brain. 

Such  a classification  is  not  exempt  from  criticism.  It  comprises 
only  the  morbid  species. 

As  it  is  impossible  to  have  a classification  in  which  all  the  indi- 
vidual psychopathic  forms  can  be  categorized  in  a rational  manner, 
so  also  must  we  definitely  abandon  any  attempt  at  a classification 
which  has  as  a basis  the  physiological  phases  of  life.  Here  we  have 
the  substitution  of  an  individual  factor  which  gives  a decidedly 
personal  imprint,  and  must  be  valued  in  each  case  with  relation  to 
the  previous  history  of  the  patient.  Such  a classification  would 
lead  to  great  confusion,  and  would  in  no  way  assist  in  giving  us  a 
plausible  orientation.  If  we  have  formed  the  conviction  that  the 
so-called  puerperal  psychosis  assumes  diverse  clinical  aspects,  what 
do  we  gain  by  denominating  all  these  various  maladies  puerperal 
insanity,  and  not  assigning  the  proper  name  to  each  syndrome  or 
to  each  morbid  form,  which  may  be  a melancholia  or  a sensory 
psychosis  or  something  else  ? And,  again,  do  we  gain  any  clearer 
knowledge  by  attributing  a clinical  individuality  to  hebephrenia,  the 
insanity  of  adolescence  ? 

The  clinical  character  of  each  malady,  in  the  case  of  those 
recognisable,  should  be  at  all  ages  the  true  and  only  denominators 
of  the  affection,  as  they  are  the  points  of  recognition  in  mental 
and  clinical  pathology.  The  individual  varieties  and  those  related 
to  age  are  contingencies  which  the  clinician  must  value  time  after 
time.  Thus  it  is  that  we  speak  of  senile  dementia  and  not  senile 
insanity,  because,  given  a psychopathy  in  an  old  man,  eithei 
there  was  previously  a mental  deficit  which  has  now  become  accentu- 
ated and  is  dementia,  or  there  was  no  such  deficit.  In  the  latter 
case  the  aged  may  present  the  most  diverse  clinical  pictures,  with 
no  particular  characteristics  other  than  they  derive  from  those 
special  to  the  mind  of  the  old  man  and  his  legitimate  preoccupa- 
tions, which  do  not  alter  the  fundamental  notes  of  the  malady. 

We  have  added  aphasic  dementia,  with  all  its  varieties,  on 


428 


PSYCHIATRY 


account  of  the  conspicuous  features  that  contradistinguish  it  from 
all  other  forms  of  dementia,  and  all  those  caused  by  destructive 
foci  in  the  brain,  not  localized  in  the  zone  of  language. 

We  spoke  of  not  blinding  ourselves  with  regard  to  the  vulnerable 
aspects  of  this  classification.  Someone  assuredly  will  observe  that 
idiocy  might  also  be  classified  in  the  last  group,  because  idiocy, 
as  a rule,  is  produced  by  diffuse  or,  more  often,  circumscribed 
cerebral  lesions. 

But  I have  already  said  that  the  classification  cannot  be  based 
on  one  characteristic  alone,  but  on  several,  together  with  that 
leading  one  which  points  more  strongly  and  particularly  to  one 
group  than  to  the  others.  Thus  it  is  that  in  the  first  group,  no 
matter  what  the  causative  agents,  there  is  always  recognizable 
a primary  defect  through  arrest  of  cerebral  development  ; in  the 
second  group,  no  matter  what  the  clinical  forms,  there  always 
remains  the  fundamental  fact  that  the  malady,  in  developing, 
surprises  the  mental  vigour  in  full  functional  effiorescence,  and, 
according  to  the  modern  views,  through  an  altered  chemistry  ; 
in  the  third  group  the  malady  attacks  fully  and  regularly  developed 
individuals,  and  shows  a great  prevalence  of  somatic  phenomena 
and  psychic  symptoms,  which,  as  a rule,  are  characterizable  as  a 
deficit  in  prevailing  relation  with  the  localizations  of  the  destructive 
processes  and  with  the  diffuse  degenerative  processes  in  the  cerebral 
substance. 

We  shall  describe  in  a single  chapter,  without  classification,  the 
secondary  dementias.  All  the  mental  affections  of  the  second 
group,  and  many  of  the  first,  after  a long  duration,  and  when  they 
do  not  recover,  give  rise  to  phenomena  characteristic  of  mental 
decadence,  which  frequently  is  slowly  progressive.  The  secondary 
dementias  present  a number  of  general  symptoms,  always  identical, 
whatever  the  clinical  form  from  which  the  particular  symptoms 
are  derived  : they  represent  only  a residual  quid  of  the  former 
personality,  associated  with  another  group  of  facts  referring  to 
the  primary  uncured  mental  malady,  which  has  lost  some  of  its 
characteristics. 


r 


j. 


CHAPTER  III 
PHRENASTHENIAS 

Under  the  name  phrenasthenia  are  comprised  all  the  forms  of  defec- 
tive evolution  of  the  mind.  They  constitute  a very  numerous 
family,  the  individual  members  of  which,  differ  very  widely  from  one 
another,  especially  in  the  extreme  degrees,  from  those  who  present 
only  a more  or  less  anomalous  and  degraded  form  of  the  human 
being  and  a mentalization  comparable  or  much  inferior  to  that  of 
the  quadrumanes  or  other  mammals,  rising  by  degrees  up  to  those 
who  live  in  society  and  participate  with  labour  in  the  common  life. 

These  last,  however,  present  a very  appreciable  mental  weak- 
ness, especially  in  the  mental  synthesis  and  in  the  intellectual  and 
emotional  manifestations  of  the  mind,  the  value  of  which  is  calcu- 
lated less  on  its  own  merits  than  in  its  social  relations. 

Many  psychiatrists  have  taken  pains  to  arrive  at  the  constitution 
of  subgroups  belonging  to  the  numerous  class  of  the  phrenastheniacs ; 
this  is  the  outcome  of  a natural  tendency  to  categorization,  but  the 
truth  is  that  the  passage  between  the  extreme  representatives  of  the 
class  is  so  gradual  that  any  division  whatever  becomes  artificial. 
At  the  most,  a logical  distinction  might  be  based  on  the  difference  of 
the  causes  determining  the  phrenasthenias. 

In  some,  indeed,  we  have  to  deal  with  a simple  evolutionary 
defect  of  varying  degree,  not  caused  by  any  anatomo-pathological 
process  arising  during  the  cerebral  development  ; in  others,  again, 
the  evolution  is  arrested  or  deviated  by  a diffuse  or  circumscribed 
pathological  process  in  the  brain  or  its  membranes  ; while,  in  a third 
group,  the  arrest  is  caused  by  particular  forms  of  intoxication. 
These  last  constitute  the  myxoedematous  group  and  that  of  the 
cretins.  The  distinction  on  this  basis  is  a logical  one,  and  responds 
■ to  a reality.  Having  regard,  however,  purely  to  the  psychic  mani- 
festations, there  are  no  points  where  we  can  draw  lines  of  separation 
dividing  into  groups  the  representatives  of  this  numerous  class, 
which  goes  by  infinitely  small  degrees  from  almost  absolute  amentia 
to  the  numerous  and  multiple  interlockings  of  weaklings  who  live 
mingled  with  the  weaker  normal  individuals,  but  in  all  cases 

429 


430 


PSYCHIA  TRY 


differ  from  those  who  in  each  country  give  the  mean  standard  of 
mentality  of  the  race  concerned. 

Nevertheless,  we  cannot  free  ourselves  from  the  traditional 
nomenclature  of  idiots,  imbeciles,  and  weak-minded,  adopted  now 
for  a long  time  by  the  majority  of  writers;  but  it  must  be  clearly 
understood  that  we  do  not  mean  to  signify  by  these  names  well- 
distinguished  groups,  but  simply  stronger  differences  of  inter- 
mediate and  extreme  degrees  of  arrest  of  development. 

Idiotism  or  idiocy  comprises  the  least  evolved  of  all  (lowest 
phrenastheniacs),  imbeciles  come  next,  then  the  cretins  (medium 
phrenastheniacs),  and  lastly  the  weak-minded  (highest  phrenas- 
theniacs). It  goes  without  saying  that  those  comprised  in  the  group 
of  idiots  present,  in  their  turn,  an  extensive  gradation  from  the 
lowest  to  the  highest,  who  become  blended  with  the  imbeciles.  The 
most  evolved  of  this  last  group  become  blended  with  the  simply 
weak-minded,  in  the  same  way  that  the  most  evolved  of  these 
become  confounded  with  the  normal.  In  their  mental  development 
the  cretins  resemble  imbeciles  more  than  idiots,  in  the  majority  of 
cases  ; but  they  form  a group  by  themselves  as  regards  both  form 
and  genesis,  and  we  shall  consider  them  separately. 

It  is  said  that  idiots  do  not  possess  language,  or  have  a very 
rudimentary  and  poor  one,  while  the  most  evolved  imbeciles  speak 
like  sane  persons,  except  that  they  show  poverty  of  thought.  But 
so  far  as  speech  is  concerned,  our  former  general  remarks  about  the 
mentalization  of  these  beings  holds  good  : there  exists  a very  gradual 
transition  in  the  imperfect  formation  and  manifestation  of  language, 
which  does  not  permit  a clear  distinction  between  the  two  groups. 
In  fact,  Sollier  himself,  who,  amongst  many,  has  made  a most  de- 
tailed study  of  the  mind  and  language  of  phrenastheniacs  (Psycho- 
logie  de  V idiot  et  de  V imbecile,  1901),  is  obliged  to  admit  to  the 
group  of  the  idiots  the  lowest  and  the  highest  degrees,  and  to  that 
of  the  imbeciles  the  same  extremes  of  a long  gradation. 

General  Symptomatology . — In  the  symptomatological  exposition 
we  shall  not  follow  any  differential  criterion  distinguishing  idiots 
from  imbeciles  and  imbeciles  from  weak-minded,  for  by  so  doing  we 
should  have  to  repeat  ourselves,  and  this  we  wish  to  avoid.  There 
is  only  one  fundamental  conception,  only  one  psychopathological 
symptomatology,  which  stretches  from  the  pronounced  tints  and 
the  decisive  lines  of  idiocy  to  the  hardly  perceptible  blendings 
presented  by  the  weak-minded  and  by  many  cretins,  who  also 
exhibit  all  grades  of  defective  mental  evolution. 

Still  less  can  we  follow  in  this  treatise  the  views  of  certain  authors, 
especially  of  Ireland,  who  form  many  subgroups  of  idiocy.  Ireland, 
in  fact,  forms  twelve  subgroups  corresponding  to  so  many  character- 
istic features  (‘  Mental  Affections  of  Children,’  1898).  If  the  descrip- 
tion of  the  forms  assumed  by  idiocy  is  facilitated  in  this  manner, 
the  pathological  conception  becomes  confused.  The  evidence  of  the 


PH  RENA  S THEN  I A S 


431 


clinical  and  anatomo-pathological  facts  suggests  to  us  three  dis- 
tinctions.  Clinically,  indeed,  we  can  distinguish  idiots  and  imbeciles 
into  (a)  a primary  group  comprising  all  those  who  are  neither 
epileptic  nor  paralytic,  and  who,  as  a rule,  are  microcephalic  ; {b)  a 
second  group  comprising  the  phrenastheniacs  (imbeciles  or  idiots) 
who  at  the  same  time  are  epileptic  and  paralytic  (and  we  might 
prolong  the  enumeration  by  adding  also  the  choreic)  ; and  (c)  a third 
group,  well  distinguished  clinically,  comprising  the  myxoedematous 
idiots.  The  distinction  under  the  anatomo-pathological  aspect  is 
founded  on  the  fact  that,  while  in  a number  of  cases  we  have  to  deal 
with  an  arrest  of  development  by  a primary  defect  of  the  evolutionary 
capacity,  in  other  cases  we  have  anatomo-pathological  processes 
coming  into  play,  destroying  one  part  of  the  brain  and  hindering  the 
development  of  the  remaining  part.  The  third  group  is  characterized 
by  defective  development  of  the  thyroid  body.  In  every  way  I 
prefer  a general  description  of  the  psycho-somatic  character  of  the 
idiot  and  of  the  imbecile,  substituting  for  the  more  detailed  descrip- 
tions some  clinical  observations  very  fully  reported. 

On  examining  the  manifestations  of  the  psychic  life  of  the  idiot, 
there  is  always  evident  a marked  defect  of  all  the  mental  activities. 
There  is  nearly  always  complete  absence  of  the  highest  activities. 
Commencing  with  the  sensations,  these  are  found  to  be  more  or  less 
imperfect,  sometimes  entirely  wanting.  From  the  earliest  months 
a mother  frequently  notices  that  her  infant  does  not  see,  or  does  not 
fix,  objects.  The  look  is  vague  and  uncertain,  as  though  directed 
into  space.  The  power  of  accommodation,  which  is  one  of  the 
motor  manifestations  of  attention,  is  defective.  Some  behave 
thus  even  in  later  childhood  and  adolescence.  Sometimes  they 
stop  too  long  on  one  object,  as  if  no  other  attraction  were 
present,  and  as  if  the  visual  field  were  restricted  to  a single  point, 
and  even  it  they  do  not  perceive  clearly,  nor  do  they  form  a well- 
defined  and  reproducible  image  of  it.  It  is  difficult  to  assert  that 
they  recognize  colours  even  when  they  are  older.  Possibly  some  of 
the  strongest  are  perceived,  such  as  red  and  orange  ; but  even  when 
they  do  notice  differences  in  colours  it  often  happens  that  they  do  not 
know  their  names.  They  are  not  even  capable  of  recognizing  the 
forms  of  objects,  or,  at  least,  a good  number  of  them,  so  as  to  cate- 
gorize them  and  attain  the  abstract  knowledge  of  forms  and  volumes. 

As  in  the  case  of  sight,  so  also  of  hearing ; sometimes  it  is  entirely 
wanting,  and  it  is  well  not  to  confuse  these  cases  with  deaf-mutism, 
in  which,  as  a rule,  there  is  a marked  defect  of  intelligence.  Most 
frequently  we  have  to  deal  with  pseudo-deafness — due  to  failure  of 
the  power  of  attention. 

The  tactile  sensibility  is  blunted.  Sometimes  it  appears  totally 
absent.  I have  experienced  extreme  difficulty  in  investigating  it. 
If,  remaining  out  of  sight,  we  surprise  an  idiot  of  the  lowest  grade 
by  means  of  tactile  stimuli  applied  to  the  face,  the. scalp,  the  hands. 


432 


PSYCHIATRY 


or  other  exposed  parts  of  the  body,  he  often  gives  no  sign  of  having 
perceived  them.  It  is  necessary  to  repeat  the  contact  several  times, 
intensifying  it  so  as  to  reach  the  threshold  of  pain,  in  order  that  he 
may  give  a sign  of  feeling.  Sometimes  even  small  punctures  are  not 
noticed,  but  stronger  pains  are  almost  always  felt.  As  in  sight  and 
hearing,  so  also  we  have  in  these  cases  not  so  much  a true  absence 
as  a greater  bluntness,  torpor,  marked  defect  of  attention,  percep- 
tion, and  reaction. 

We  meet  with  greater  defect  in  taste  and  smell.  Mantegazza, 
in  one  of  his  many  popular  books,  wrote  : ‘ Tell  me  what  you  eat,  and 
I will  tell  you  what  you  are.’  It  would  be  better  to  say,  ‘ Tell  me 
how  you  eat,’  etc.  As  a rule,  idiots  are  voracious  ; sometimes  they 
do  not  make  any  distinction  between  one  food  and  another  ; when 
eating,  they  very  often  plunge  the  whole  hand  into  the  bowl,  over 
which  they  bend  with  greedy  mouth,  allowing  some  of  the  food  to 
fall  over  the  face  and  on  the  clothing,  and  they  soil  themselves  to  such , 
an  extent  that  it  is  impossible  to  make  them  sit  at  the  same  table 
as  other  patients.  They  take  their  food  with  either  the  right  or 
left  hand ; if  they  have  several  dishes  in  front  of  them,  they  mix 
everything  in  a single  bowl — bread,  cake,  wine,  meat.  They  collect 
the  crumbs  and  the  morsels  that  have  fallen  on  the  ground,  and  put 
even  the  filthiest  things  in  their  mouths ; in  the  lowest  grades,  idiots 
do  not  even  make  that  selection  of  food  which  is  so  characteristic 
of  all  the  higher  animals  ; they  swallow  everything.  At  the  autopsy 
of  some  idiots,  especially  those  confined  in  public  hospitals  and 
asylums  where  not  much  care  is  taken  of  them,  it  is  not  a rare  thing 
to  find  the  stomach  full  of  straws,  paper,  hairs,  and  remedial  articles. 

Sometimes  they  do  not  distinguish  the  bitterness  of  colocynth 
from  the  sweetness  of  sugar.  It  is  needless  to  speak  of  the  different 
tastes  of  the  delicate  viands  that  an  elegant  table  offers  or  that  a 
refined  cook  prepares ; or  of  the  different  odours  that  remain 
definitely  outside  the  threshold  of  perception  in  idiots  even  not 
of  the  lowest  grades. 

The  time  of  reaction  is  much  longer  in  phrenasthenic  than  in 
normal  individuals  (Buccola). 

Avidity  for  alcoholic  beverages  is  frequent,  especially  when 
there  is  an  alcoholic  heredity,  which  is  not  very  rare. 

The  bluntness  and  the  evolutionary  defect  of  the  senses  give 
us  an  idea  what  to  expect  of  the  intellect  of  idiots. 

Certainly  they  sometimes  form  a larger  or  smaller  patrimony 
of  concrete  images  of  objects,  so  that  idiots  recognise  a number 
of  persons  and  a number  of  objects  and  places  ; but  it  is  always 
restricted  as  compared  with  that  of  the  evolved  man.  They  also 
liave  desires,  and  sometimes  make  requests  in  their  own  fashion. 
They  are  capable  of  forming  groups  of  associated  images  and  general 
categories,  more  or  less  extensive  and  comprehensive,  especially 
tliose  of  them  who  are  somewhat  evolved.  But  they  never  arrive 


PHREN  ASTHENIA 


433 


at  intellectual  syntheses  demanding  a large  association  and  a more 
complete  fusion  of  concrete  images,  besides  a very  large  number 
of  images  differentiated,  categorized,  and  well  conserved. 

Slight,  and  sometimes  even  great,  differences  between  similar 
things  escape  the  notice  of  the  idiot.  He  gathers  only  the 
general  features  of  persons,  objects,  and  places  surrounding  him  , 
in  the  same  way,  all  the  blendings  of  colours  escape  him,  although 
he  be  able  to  distinguish  red  from  blue  and  orange,  and  hence  he 
confuses  many  things  that  differ  from  one  another.  He  tends  to 
generalize,  not  by  a process  of  synthesis,  but  through  a defect  of 
differentiation.  If  he  learns  the  name  of  one  nurse,  he  calls  all  the 
others  dressed  in  like  manner  by  the  same  name.  A certain  idiot 
succeeded  in  learning  to  distinguish  the  medical  officers  from  the 
attendants  and  the  latter  from  the  patients,  but  for  a long  time  was 
unable  to  distinguish  the  different  doctors,  and  it  was  only  after 
long  exercise  that  he  was  able  to  distinguish  the  superintendent 
from  the  medical  officers.  A microcephalic  idiot  confined  in 
the  Sales  Asylum  called  all  the  men  she  saw  ‘ papa,’  and  all  the 
nurses  and  female  patients  ^ mamma  or  auntie,  without  being 
able  to  make  any  distinction  between  them. 

They  do  not  understand  ordinary  language  in  all  its  extent,  but 
only  some  words  which  they  can  refer,  by  long  practice,  to  some- 
thing pleasant  or  unpleasant,  or  to  some  person  well  known  to  them 
through  long  association.  As  a rule,  even  this  association  is  vague 
and  superficial.  The  associative  power  is  rudimentary,  and  the 
judgment  of  individual  sensations  is  simple  and  immediate. 
There  is  no  intellectual  resource  revealing  any  imaginative  power 
whatsoever  ; if  they  were  not  cared  for  they  would  die. 

How  much  inferior  is  their  intelligence  to  that  of  the  monkey  ! 
If  we  give  to  a monkey  fond  of  cherries  one  dipped  in  a solution  of 
quinine,  it  thinks  out  the  plan  of  peeling  it  and  eating  only  the 
mesocarp,  which  is  not  bitter  ; greedy  as  it  is  for  sugar,  if  we  give  it 
some  in  a small  bottle,  from  the  bottom  of  which  it  can  find  no 
mode  of  raising  it,  after  having  in  vain  attempted  to  reach  the 
bottom  with  its  short  finger,  in  a moment  of  strong  avidity  it  is 
able  intuitively  to  conceive  the  idea  of  breaking  the  bottle,  taking 
it  by  the  neck  and  dashing  it  with  force  to  the  ground.  The  mind 
of  the  worst  idiots  is  often  devoid  of  similar  resources.  The  intelli- 
gence and  attitude  of  many  resemble  those  of  the  dog.  This 
resemblance  has  been  most  clearly  shown  by  Sciamanna.  Briefly 
put,  the  fund  of  displaceable  images  is  very  poor,  and  is  capable 
of  but  little  association,  and  hence  is  of  small  utility. 

The  idiot  may  form  empirical  judgments  for  himself,  through 
the  experiences  of  the  proper  senses  ; he  will  recognise  cutting, 
pungent,  scalding,  glittering,  sonorous  bodies,  with  which  only 
sometimes  does  he  associate  the  verbal  symbol.  He  avoids  or 
approaches  such  bodies  or  persons  in  his  environment  according  to 

28 


434 


PSYCHIATRY 


the  experience  he  has  had  of  them.  If  on  a former  occasion  he  has 
been  bitten  by  a dog,  he  will  run  away  from  that  dog  ; if  he  was 
tormented  and  irritated  by  rogues,  he  will  chase  them  or  assail  them 
with  stones  ; he  will  also  arrive  at  a general  idea  of  money,  as  is 
noted  in  wandering  beggars  of  the  imbecile  grade  of  evolution 
(Maffei,  Emminghaus). 

The  general  plan  of  their  mental  organization  might  be  repre- 
sented in  a scheme  containing  some  sensory  elements  which  are 
common  to  many  objects,  and  hence  give  rise  to  confusion  and  error 
in  judgments  of  recognition.  A piece  of  chalk  is  mistaken  for  a 
piece  of  sugar  (as  happens  in  monkeys  after  mutilation  of  the  frontal 
lobes),  an  instantaneous  light  is  mistaken  for  a flash  of  lightning, 
a loud  noise  for  thunder. 

The  most  definite  empirical  conception  that  the  idiot  may 
form  is  that  of  his  own  identity,  of  his  proper  ego.  With 
sensory  experience,  with  the  succession  of  his  own  feelings, 
under  the  influence  of  external  stimuli,  with  the  repetition  of 
interests  relative  to  his  own  person,  he  arrives  at  distinguish- 
ing the  ego  from  the  non  ego.  As  these  sensations,  experiences, 
and  interests  are  infinitely  less  numerous  in  the  idiot  and 
even  in  the  imbecile  than  in  the  normal  individual,  so  the 
idiot  arrives  at  a read}^  formation  of  the  empirical  conception 
of  self,  joined  with  the  satisfaction  of  the  proper  instincts,  and 
hence  the  enormous  preponderance,  even  frequently  the  exclusive 
dominion,  of  egoism.  His  ego  lacks  infinite  associated  groups 
and  abstract  categories  freed  from  the  immediate  sensual  images, 
as  well  as  the  relation  of  cause  and  effect,  and  the  difference  between 
meum  and  tuum,  between  the  useful  and  the  hurtful.  Thence  arise 
all  the  errors  and  all  the  dangers  connected  with  the  conduct  of 
the  idiot,  and  especially  the  imbecile.  Being  deprived,  especially 
through  deficiency  in  associations  by  contrast,  of  a rich  fount  of 
intellectual  resources  and  judgments — which  in  the  phrenasthenic 
are  formed  merely  on  the  basis  of  a few  features  of  resemblance 
the  conclusions  of  identity  or  want  of  identity  are  often  erroneous, 
and  the  correlative  action  is  fulfilled  only  in  the  interest  and  under 
the  directive  influence  of  an  agreeable  or  disagreeable  feeling  of  a 
sensual  nature. 

The  process  of  perception,  internal  and  external,  being  defective 
in  him,  he  is  deprived  of  the  final  result  of  the  function  of  the  senses 
as  regards  cognition,  and  everything  becomes  reduced  to  fixing  the 
gaze  on  shining  objects  made  conspicuous  by  strong  colours,  and 
on  fire  more  than  anything  else.  A blazing  flame  gives  great 
pleasure  to  idiots  and  imbeciles ; with  this  pleasure  is  associated 
the  empirical  acquaintance  with  inflammable  substances.  Thus 
it  is  that  they  sometimes  derive  pleasure  from  setting  fire  to  things, 
(case  of  Spielmann).  Sometimes  they  dream  of  a fire  or  a con- 
flagration, and  may  carry  the  dream  into  effect,  the  dream  being  to- 


PHRENASTHENIA 


435 


them  like  an  invitation  or  a suggestion,  unrestrained  by  any  other 
consideration  such  as  damage  or  danger,  as  in  the  case  of  Heinroth. 

With  this  fact  coincides  great  defect  of  attention  and  of  memory, 
^^oluntary  attention  is  so  constantly  defective  in  the  idiot  that 
Sollier  bases  the  distinction  of  the  grades  of  idiocy  upon  its  degree 
of  development.  Spontaneous  or  sensory  attention  is  always 
present,  but  even  this  shows  various  degrees,  according  to  the  grade 
of  perceptive  capacity.  In  the  dess  severe  forms  the  educability 
of  the  phrenasthenic  holds  some  relation  to  the  possibility  of  trans- 
forming spontaneous  into  voluntary  attention.  The  most  pro- 
nounced idiots,  by  reason  of  the  impossibility  of  such  transforma- 
tion, are  not  educable.  On  the  other  hand,  the  attention  is  unstable. 

Many  idiots,  particularly  the  hereditary,  pass  with  great  rapidity 
from  one  thing  to  another  falling  under  their  torpid  senses,  without 
fixing  the  features  of  any.  Even  imbeciles  present  in  a minor 
degree  the  same  instability  or  marked  exhaustibility  of  attention. 
There  are  some  idiots  and  imbeciles  who  seem  to  pay  attention  to 
things,  but  it  is  no  more  than  an  external  semblance,  because,  as 
a matter  of  fact,  they  neither  perceive  nor  fix,  almost  as  though 
the  mind  were  absorbed  or  preoccupied,  while  in  reality  it  is 
void,  and  they  have  only  the  muscular  attitude  of  attention.  From 
this  point  of  view  we  may  divide  phrenasthenics  into  mobile  or,  as 
others  call  them,  dissipated  distracted  and  absorbed  distracted. 

The  memory  of  phrenasthenics  presents  greater  variation  than 
the  attention  ; the  most  pronounced,  those  at  the  lower  end  of  the 
scale,  remember  only  those  persons  who  take  care  of  them  and  the 
objects  that  make  the  deepest  impression  on  them  in  the  satisfaction 
of  the  fundamental  instincts  (food,  water,  wine),  or  instruments  and 
persons  that  have  caused  them  to  feel  pain.  Proceeding  by  degrees, 
others  remember  a large  number  of  impressions  referable  to  them- 
selves, to  places,  persons,  and  events.  We  can  state  it  as  a law 
that  everything  that  is  not  fixed,  owing  to  defect  of  attention,  is 
neither  conserved  nor  reproducible.  Even  in  the  higher  evolved 
phrenasthenics,  however,  memory  is  fragmentary,  unreliable,  torpid, 
so  that  we  cannot  place  reliance  on  what  imbeciles  tell  us  ; above 
all,  precision  as  regards  the  memories  of  time,  place,  and  persons 
is  defective,  so  that  mistakes  are  frequent. 

Vice  versa,  the  mechanical  memory  is  in  many  cases  highly 
developed.  Many  idiots  of  a rather  low  degree  have  a good  memory 
for  musical  movements  (cases  of  Ferrari,  reported  in  the  second 
part).  Some  remember  forms  well,  so  that  they  are  able  to  repro- 
duce them  (cases  of  Griesinger,  Bourneville,  Ireland).  Others 
have  a good  memory  for  places  ; the  cretins,  for  example,  remember 
places  in  the  woods  where  they  go  and  hide  their  foodstuffs  (Maffei, 
reported  by  Emminghaus).  It  is  quite  apparent  in  these  cases 
that  the  sense  of  direction  is  also  well  developed  (resemblance  to 
animals).  Others,  again,  can  learn  a page  of  writing  after  a single 

28 — 2 


436 


PSYCHIA  TRY 


reading,  without  having  understood  it,  and  repeat  it  with  surprising 
precision.  Drobisch  speaks  of  an  idiot  child  who,  through  the 
untiring  zeal  of  a noble  signora,  had  been  able  to  learn  to  read 
quickly,  and  to  repeat  a whole  page,  word  for  word,  without  any 
idea  as  to  its  meaning.  Guggenbiihl  reports  the  case  of  a child 
(examined  by  Spielmann)  who  was  able  to  indicate,  by  its  broken 
language  and  with  the  aid  of  mimicry,  the  days  of  the  birth  and  the 
death  of  every  inhabitant  in  his  community.  An  imbecile,  confined 
in  the  Naples  asylum,  remembered  the  saints  for  each  day  of  the 
calendar.  Others  possess  a strong  memory  for  numbers,  so  that 
they  can  do  calculations  very  rapidly  by  memory — e.g.,  multi- 
plications and  divisions  of  several  ciphers  (vide  Part  II.).  The 
distinction  between  the  memory  of  the  normal  man  and  that  of 
the  phrenasthenic  lies  principally  in  this,  that  the  phrenasthenic, 
through  defect  of  associative  power,  does  not  utilize  the  mnemonic 
patrimony  in  the  various  circumstances  of  life,  but  reproduces  it 
as  a stereotype  in  single  circumstances.  In  the  low-grade  idiot 
there  is  entire  absence  of  that  process  of  decomposition  and  recom- 
position, based  on  memory  and  characterizing  the  normal  mind, 
which  can  give  with  the  same  material  the  most  varied  products  ; 
while  in  the  imbecile  it  is  present  only  to  a slight  extent. 

For  the  same  reason,  the  imitative  faculty,  which  plays  such  a 
great  part  in  the  education  of  the  normal  child,  is  in  phrenasthenics 
a reflex  act.  What  they  imitate  is  not,  as  a rule,  understood. 

Credulity  is  a characteristic  common  to  very  many  of  them. 
The  imbecile  and  the  idiot  who  is  not  of  the  lowest  grade  may  be 
made  to  believe  even  the  most  improbable  things,  and  sometimes 
it  is  difficult  to  dissuade  them  from  believing  what  they  have  once 
considered  to  be  true.  They  are  ridiculous  even  in  their  incredulity. 
The  more  highly  evolved  of  them  (imbeciles)  readily  accept  the 
hyperbolic  compliments  and  the  homage  paid  to  them  in  jest,  and 
this  may  even  give  rise  to  paranoic  attitudes  resulting  in  a curious 
demeanour  of  ridiculous  vanity. 

They  never  take  a true  interest  in  persons,  things,  or  events  ; 
they  are  lacking  in  initiative.  If  commanded,  they  obey,  when 
capable  of  comprehending  the  command  and  of  acting  thereon, 
although  in  some  cases  they  absolutely  refuse  to  do  so. 

Incapacity  to  appraise  things  and  events,  through  absence  of 
images  of  contrast,  due  to  great  poverty  of  the  memory,  explains 
the  great  number  of  apparently  criminal  acts  committed  by  such 
phrenasthenics,  and  the  accessions  of  rage  to  which  they  are  subject. 
Some  react  violently  and  ferociously  on  refusals  to  satisfy  their 
wishes,  as,  for  example,  in  the  classic  case  of  Calmeil  to  which 
Marc  makes  reference.  One  imbecile  whom  I examined  in  prison 
and  found  submicrocephalic  had  struck  his  mother  for  a trivial 
reproof  she  had  given  him.  Sometimes  imitative  outbursts  occur 
— e.g.,  an  imbecile,  seeing  his  sister  beaten  by  her  husband,  assaulted 


PHRENASTHENIA 


437 


the  latter  with  an  axe,  which  was  found  in  his  hand,  and  injured 
him  so  severely  that  he  died  from  his  wounds  two  days  later. 
(Emminghaus). 

In  the  high  grades  of  idiocy  and  in  imbecility  a due  significance 
may  even  be  attached  to  the  words  wrong,  punishment,  forhiddance, 
but  such  significance,  instead  of  being  abstract,  is  always  associated 
with  the  memory  of  actions  done  by  the  individual  himself  and  with 
the  punishment  and  torture  suffered  in  consequence. 

It  is  needless  to  spend  many  words  in  showing  that  the  emotions 
of  phrenasthenics  never  reach  that  high  grade  of  evolution  that 
renders  possible  the  fusion  of  the  individual  emotions  with  those  of 
the  social  environment,  by  means  of  which  the  normal  man  attains 
the  highest  summits  of  sentimentality.  In  all  grades,  the  emotions 
are  ever  elementary  and  primitive  ; in  the  higher  evolved  they  find 
expression  in  egoistic  sentiments.  Sometimes  even  the  most 
fundamental  emotions,  such  as  those  of  hunger  and  of  thirst,  are 
wanting,  or  are  rudimentary  or  roughly  outlined  (Bourneville). 
In  some  cases  they  are  expressed  only  by  a cry.  An  idiot,  sent  to 
my  clinique  from  a large  hospital  in  the  city,  cried  at  the  top  of 
her  voice  every  time  she  was  hungry,  until  they  gave  her  food  with 
a spoon,  or  put  into  her  hand  pieces  of  bread,  which  she  devoured 
ravenously.  She  used  to  remain  quiet  for  hours,  so  long  as  she  felt 
no  appetite,  and  then  she  would  commence  her  loud  cries. 

The  highest  sentiments  of  the  most  evolved  phrenasthenics 
have  the  appearance  of  altruism  ; yet  the  attachment  or  apparent 
tenderness  of  phrenasthenic  children  to  their  mothers  or  some  other 
relative  is  immediately  connected  with  the  pleasure  and  satisfaction 
of  the  fulfilment  of  all  their  requests,  which  the  poor  mothers  often 
divine.  The  piety  of  the  majority  of  imbeciles  is  imitated  in  its 
exterior  mechanism,  or  connected  with  the  suggested  fear  of  fire 
and  the  devil. 

Chastity,  especially  in  women,  is  likewise  imitated.  Maffei 
mentions  a good  example  in  the  case  of  a young  imbecile  who  was 
unwilling  to  expose  her  chest  to  the  doctor  who  had  to  examine 
her,  yet  soon  afterwards  went  outside  the  entrance  to  the  house 
to  urinate,  exposing  herself  without  concern  to  the  people  who  were 
passing.  The  obedience  of  many  imbeciles  arises  from  their 
mechanical  type  of  nature ; their  personality  does  not  manifest  itself 
with  any  strong  desire  or  with  any  intrinsic  and  endogenous  energy. 

The  morality  of  many  imbeciles  who  neither  steal  nor  react,  who 
support  in  peace  and  with  patience  even  angers  and  injuries,  is 
only  apparent ; the  fact  is  that  they  experience  no  desires,  nor  do 
they  feel  the  emotions  that  sway  every  evolved  person,  such  as 
personal  dignity,  humiliation,  etc.,  or  the  desire  is  weak,  fleeting, 
overcome  by  the  fear  of  punishment,  unaided  by  all  those  intel- 
lectual resources  by  which  the  normal  man  seeks  in  every  way  to 
escape  from  it. 


438 


PSYCHIATRY 


From  this  point  of  view  we  must  distinguish  two  classes  of 
phrenasthenics  : (i)The  moraloid,  who  are  those  of  whom  we  have 
just  spoken  ; (2)  the  immoral,  who  are  very  dangerous  beings, 
inclined  to  falsehood,  theft,  calumny,  vagabondage,  idleness,  want 
of  discipline  : they  are  violent,  obstinate,  stubborn,  pretentious 
in  one  sphere  of  ideas  and  desires,  very  limited  in  another.  We 
have,  for  example,  the  timid,  fearful  imbecile,  who  tells  the  truth 
because,  like  a child,  he  is  unable  to  formulate  a lie  with  readiness, 
especially  when  it  is  concerned  in  the  avoidance  of  punishment  ; 
the  imbecile  who  respects  the  property  of  others  with  the  fidelity 
of  a mechanism,  and  the  imbecile  who  steals  ; the  imbecile  who  does 
not  love  at  all,  either  platonically  or  sensually,  and  the  lascivious 
imbecile  who,  without  any  regard,  seizes  persons  of  the  other  sex, 
be  they  his  own  sisters  or  his  own  mother,  without  a shadow  of 
chastity  and  without  giving  any  thought  to  the  dangers,  damages, 
and  inconveniences.  • Emminghaus  reports  the  well-known  case 
of  Rdsch  dealing  with  an  idiot  who  from  time  to  time  attacked  his 
own  mother  in  an  accession  of  erotic  fire,  and  from  whom  she  was 
liberated  only  after  a great  struggle  ; the  unfortunate  woman  had 
to  shout  at  the  top  of  her  voice  till  her  neighbours  came  running 
up,  and  succeeded  with  blows  from  sticks  in  liberating  her  from 
her  beastly  and  lascivious  son  (remarkable  resemblance  to  the 
asses).  I have  at  present  in  the  asylum  a young  imbecile  whose 
confinement  was  called  for  principally  because  in  the  night-time, 
in  the  evening,  and  sometimes  during  the  day,  when  one  of  his 
sisters  was  in  bed  and  he  supposed  her  asleep,  he  used  to  approach 
as  openly  as  if  fulfilling  a perfectly  approved  action,  and  without 
a shadow  of  chastity  attempt  to  vent  upon  her  his  lascivious  desire. 

The  female  imbecile,  if  not  watched,  often  takes  to  vagabondage, 
to  idleness,  and  runs  after  men,  carrying  on  the  most  barefaced 
prostitution. 

Such  differences  in  sexual  behaviour  in  idiots  and  imbeciles 
are  certainly  related  to  the  frequency  of  anomalies  of  the  organs 
( Bourne ville  and  S oilier,  ‘ Des  anomalies  des  organs  genitaux 
chez  les  idiots  et  les  epileptiques'  Prog.  Med.,  1883).  Idiots  do 
not  show  any  jealousy  ; imbeciles,  like  monkeys,  are  very  jealous. 
Many  of  them,  however,  are  very  suspicious  and  malicious  (the 
most  evolved). 

A true  sentiment  of  commiseration  is  not  demonstrable  in 
imbeciles,  although  its  attitude  is  imitated. 

I have  never  met  with  any  feeling  of  solidarity  amongst  the 
lowest  and  middle  grade  imbeciles.  The  imbecile  is  not  moved  in 
sympathy  with  tl\e  joys  or  pains  of  others  ; on  the  contrary,  he 
enjoys  or  laughs  at  a disaster,  a scuffle,  a misfortune,  the  sight  of 
many  excited  and  agitated  people,  and  is  pleased  by  the  shouting, 
provided  he  be  in  a secure  position  and  at  a safe  distance  (Maffei). 

The  phrenasthenic  is  not  courageous — as  a rule  he  remains 


PH  RENA  S THEN  I A 


439 


unmoved  in  all  the  difficulties  of  life  ; in  the  somewhat  evolved 
idiots  and  in  imbeciles  fear  is  prevalent.  Sometimes  imbeciles 
appear  courageous,  but  it  is  audacity  rather  than  courage  ; there 
is  more  impulsiveness  than  consciousness. 

The  elementary  aesthetic  sentiments,  such  as  that  of  rhythm, 
are  more  frequent,  and  even  in  profound  idiots  the  musical  senti- 
ment is  frequently  met  with  (vide  Part  IT). 

Hereditary  idiots  possess  these  artistic  aptitudes.  Dagonet’s 
idiot  repeated  uncomplicated  airs  on  the  piano ; Morel’s  idiot  showed 
sufficient  ability  to  play  the  drum  : he  was  the  son  of  a drummer. 

In  the  lowest  grades  there  is  wanting  even  the  sentiment  of 
possession,  which,  in  some  idiots,  flourishes  under  the  anomalous 
form  of  collectionism,  or  of  appropriation  of  what  belongs  to  others, 
especially  food  and  clothing  ; when  notions  concerning  possession 
do  find  a place  in  imbeciles,  they  are  always  more  strongly  developed 
as  regards  their  own  property  than  as  regards  that  of  others. 

This  mode  of  behaviour  of  the  intelligence  and  the  sentiments  of 
phrenasthenics,  who  are  to  be  considered  not  only  from  the  point 
of  view  of  degree,  but  also  as  regards  the  disproportionate  develop- 
ment of  one  emotion  or  of  some  particular  sense  in  comparison  with 
others,  explains  the  great  differences  in  behaviour  and  the  varied 
aptitudes,  however  rudimentary,  of  idiots  in  general  and  also  of 
imbeciles.  No  matter  how  much  we  may  wish  to  classify  and  group 
together,  each  one  presents  a different  attitude,  diverse  instincts, 
tendencies,  and  aptitudes.  The  majority  of  true  idiots  lack  grace 
in  their  attitudes,  are  dirty,  squalid,  and  repugnant,  unless  great 
attention  be  paid  to  them.  They  have  a heavy  step,  and  do  not 
raise  their  feet  well  from  the  ground  (Andriani  and  Sgobbo) ; they 
are  brutal,  rachitic,  and  bent  at  the  level  of  the  shoulder  ; they 
have  a vague,  uncertain  look,  with  no  vivacity.  Sometimes  they 
recall  types  of  inferior  races,  such  as  the  Mongolian  type  (Ireland). 
Many  of  them  have  special  tics  : one  finds  pleasure  in  spinning  on 
his  heel ; another  sways  himself  continually  in  an  antero-posterior 
direction ; another  incessantly  sucks  his  thumb  or  index-finger  ; 
another  cries  like  an  animal  at  more  or  less  regular  intervals  and 
with  a certain  rhythm  ; others  ruminate  after  their  meals  like 
ruminant  animals  (mericism). 

As  regards  instincts  and  aptitudes,  we  find  in  some  the  instinct 
of  nutrition  and  a certain  capacity  for  the  search  and  selection  of 
food,  while  in  others  this  instinct  is  defective  ; some  learn  to  hold 
a spoon  and  to  eat  with  it,  others  use  their  hands,  or  put  their 
mouths  to  the  bowl  in  a repulsive  manner  ; sometimes,  though  not 
capable  of  handling  and  making  use  of  the  epoon,  they  employ  their 
hands  in  taking  hold  of  a stick,  or  in  seizing  the  branches  of  a tree, 
up  which  they  clamber  (the  microcephalic  idiot  studied  by  Sam- 
burini). 

Some  have  the  intuition  of  self-preservation,  others  have  no 


440 


PSYCHIATRY 


conception  of  danger,  but  will  put  a piece  of  glass  into  their  mouth, 
take  a knife  by  the  blade,  put  their  hands  into  the  fire  and  burn 
themselves,  and  not  hasten  to  get  out  of  the  way  of  vehicles. 

In  most  cases  idiots  do  not  engage  in  games,  but  prefer  solitude  ; 
or  even  if  the  most  highly  evolved  of  them  do  take  part  in  games, 
their  movements  are  devoid  of  an  intelligent  participation.  Whilst 
normal  children  associate,  show  inventive  tendencies,  vie  with  one 
another  in  muscular  strength,  in  running,  in  wrestling,  in  making 
practical  jokes  at  the  expense  of  others,  imbeciles  and  high-grade 
idiots  display  no  such  inclinations,  do  not  participate  in  the  merri- 
ment and  pleasure  which  in  the  normal  child  is  the  outcome  of 
his  own  stock  of  energy,  stimulated  by  contact  with  other  children. 
Imbeciles,  however,  are  often  found  in  gatherings  of  children,  but 
there  they  show  up  their  characteristic  traits  and  their  deficiencies, 
while  the  normal  children  make  fun  at  their  expense,  delighting  in 
mocking  at,  and  passing  witty  remarks  about,  their  weak  com- 
panions, who  scarcely  ever  understand  the  twofold  meaning  of 
the  words  and  the  figurative  phrases  ; on  the  other  hand,  they  are 
violent  and  brutal  because  of  the  poverty  of  their  intellectual 
resources,  and  very  often  through  the  suggestion  of  others. 

If  they  go  to  school  haphazard  with  normal  children,  they  grasp 
almost  nothing  of  the  instruction  imparted  to  them  ; indeed,  they 
cause  disorder  in  the  school.  At  the  end  of  the  year  they  represent  ' 
a passive  factor  in  the  profit,  and  an  active  factor  in  the  disorder,  ,• 
in  the  bad  behaviour,  the  bad  discipline,  the  negligence.  The  more  ' 
highly  evolved  imbeciles  sometimes  take  hold  of  the  ridiculous  ’ 
side  of  occurrences  and  persons,  imitate  and  exaggerate  ridiculous  ' 
poses,  possess  a good  memory  for  anecdotes  and  words  with  a 
double  meaning,  and  so  cause  amusement. ' Many  of  the  buffoons 
of  the  medieval  courts  were  imbeciles  (Moreau  de  Tours). 

The  higher-grade  idiot  and  the  lower-grade  imbecile  may  fly  into  j 
a fury  at  the  sight  of  men  or  animals  from  whom  at  some  time  or  j 
other  they  have  suffered  injury,  and  they  may  conceive  revenge  \ 
against  them  in  narrated  modes,  as  often  happens  in  public-houses,  -j 
If  one  of  them  has  once  seen  a conflagration  or  has  heard  tell  of  a i 
murder  subsequent  to  an  insult  to  his  own  person,  he  may  act  the 
incendiary  or  provide  himself  with  a weapon  to  attack  his  adversaiy. 

These  criminal  actions  sometimes  present  the  appearance  of 
premeditated  acts,  whilst  in  reality  they  are  not  so. 

True  accessions  of  fury  and  passions  are  also  very  frequent  in  the 
lowest  idiots — throwing  objects  violently  to  the  ground,  tearing 
their  clothes,  scratching  their  faces,  yelling,  etc. 

Some  show  tendencies  that  are  really  atavic  ; they  cannot 
endure  clothes  or  stockings,  and  they  walk  on  all-fours.  An  idiot 
who  was  for  years  confined  in  the  provincial  asylum  at  Naples, 
before  he  was  trained,  used  to  take  off  his  clothes  and  run  about 
naked  on  all-fours  under  the  beds.  Antonini’s  idiot  used  to  eat  live 


PHRENASTHENIA 


441 


chickens,  feathers  and  all,  and  it  appears  that  he  once  gnawed  away 
at  the  head  of  a live  cat. 

We  must  not  end  this  summary  of  the  mind  of  phrenasthenics 
without  mentioning  those  others,  much  more  highly  developed,  who 
might  be  considered  normal  intellectually,  who  go  to  school  and 
learn,  who  reach  the  level  of  abstractions,  who  exhibit  a normal 
development  of  language  and  employ  it  appropriately,  and  never- 
theless are  deficient,  inasmuch  as  they  show  themselves  incapable 
of  that  extensive  co-ordination  in  the  social  relations  by  means  of 
which  normal  youths  succeed  in  procuring  for  themselves  a means  of 
existence. 

Inconstancy  is  one  of  the  principal  characteristics  of  this  group  ; 
they  never  persist  in  the  direction  of  a chosen  path.  They  learn  a 
trade,  and  sometimes  succeed  in  it,  but  they  do  not  always  attain 
the  perfection  reached  by  normal  individuals  ; then,  one  day  or 
other,  they  abandon  the  office,  the  shop,  or  the  school,  and  pass  a 
longer  or  shorter  time  in  idleness,  giving  themselves  up  to  vaga- 
bondage, almost  as  if  the  will  were  exhausted  and  their  poor  and  faint 
imagination  no  longer  capable  of  representing  to  them  the  problem 
of  life.  After  a longer  or  shorter  time,  during  which  they  would 
almost  seem  to  have  accumulated  new  energies,  they  determine  to 
resume  work,  but  of  another  nature  : from  a shoemaker’s  shop  they 
pass  to  that  of  a carpenter,  or  they  join  the  ranks  of  the  porters  at 
the  harbour  or  the  railway-station,  or  learn  some  other  trade  ; but 
after  some  months,  or  it  may  be  years,  no  matter  what  the  nature  of 
their  environment,  they  are  still  found  in  a state  of  unrest. 

Whether  it  is  because  their  will  becomes  exhausted  and  they 
become  incapable  of  the  force  which  frequently  is  necessary  for 
victory  in  a life  full  of  obstacles,  or  because  they  realize  their  own 
inferiority  in  contact  with  the  normal  human  being,  this  much  is 
certain — that  they  are  often  taken  by  an  irresistible  desire  to 
abandon  the  post  which  assures  to  them  the  means  of  subsistence. 

If  they  belong  to  a higher  social  grade,  as  we  call  it,  they  pass 
into  inferior  surroundings  without  thinking  of  the  consequences, 
but  rather  with  ready  complacence.  If  they  are  scholars,  they 
soon  abandon  the  school,  and  take  to  the  sea  or  join  the  army, 
where  they  conduct  themselves  as  undisciplined  individuals,  and 
very  soon,  their  inferiority  being  recognized,  they  abandon  their 
career  in  search  of  new  employment.  Everywhere  critical  or 
fanatical,  proud  or  arrogant,  timid  or  violent,  always  inferior,  inapt, 
inadaptable,  they  live  isolated  and  neglected,  and  end  either  by 
abandoning  or  by  being  expelled  from  the  post  they  occupy,  even 
when  by  good  fortune  they  had  succeeded  in  attaining  it  with  a 
great  effort.  *. 

In  wealthy  and  aristocratic  families  the  imbeciles  of  whom  we 
are  now  treating  show  themselves  to  have  a tendency  to  a dissipated, 
instinctive  life,  abandoning  themselves  to  games,  women,  and 


442 


PSYCHIATRY 


revelry.  Their  principal  characteristic  is  the  more  or  less  evident 
absence  of  the  marks  of  good  breeding.  Their  mind  is  sterile  as 
regards  all  that  should  form  the  objective  of  a rich  and  well-bred 
family.  Their  brain  is  not  a suitable  soil  for  the  most  advanced 
culture,  and  they  are  therefore  incapable  of  providing  adequately 
for  their  future.  In  the  enjoyment  of  to-day  they  take  no  heed  of 
expense,  and  in  a short  time  go  through  even  large  fortunes.  Their 
tendency  to  indulge  in  stupid  ostentation  (and  even  in  this  they 
reveal  the  poverty  of  their  mind)  is  well  utilized  by  the  astute,  who 
speculate  on  their  credulity  and  suggestivity.  From  amongst  the 
many  examples  I might  cite,  I here  give  a brief  record  of  one  only, 
that  of  a young  man  of  a wealthy  aristocratic  family,  who  allowed 
himself  to  be  persuaded  by  coachmen  and  rogues  who  surrounded 
him  to  drive  in  a carriage  with  the  very  best  of  horses.  The  specu- 
lators provided  everything,  and  he  believed  that  the  value  of  the 
carriages  and  horses  surpassed  twelve  or  fourteen  thousand  lire, 
while  it  was  only  three  or  four  (credulity,  suggestivity).  As  he  had 
not  the  necessary  ready -money,  and  those  who  had  designs  upon  him 
had  an  eye  to  his  rich  paternal  inheritance,  they  made  him  subscribe 
a bill  of  exchange  for  thirty  thousand  lire  in  return  for  a value  of 
three  or  four  thousand  lire.  A short  time  afterwards  the  same 
persons  persuaded  him  that  he  ought  to  give  up  his  carriages, 
because  for  their  maintenance  he  had  already  been  obliged  to  sign 
bills  for  many  additional  thousands  of  lire.  He  gave  orders  to  sell 
the  carriages  and  horses,  but  realized  scarcely  a hundred  and  fifty 
lire,  and  never  once  complained  of  such  a bad  transaction.  In  the 
course  of  two  or  three  years  this  young  man  (and  I know  several 
similar  instances)  had  squandered  his  paternal  inheritance  of  three 
hundred  thousand  lire,  having  spent  effectively  no  more  than  thirty 
thousand.  A prominent  characteristic  of  this  class  of  imbeciles  is 
that  they  are  not  at  ease  in  their  family  and  in  their  own  environ- 
ment, but  find  themselves  perfectly  a son  aise  in  the  lower  social 
strata,  where  the  conversation  does  not  demand  that  mental  effort 
and  that  patrimony  of  culture  which  are  the  necessary  equipment  of 
a modern  well-bred  man.  In  this  environment  alone  do  they  find 
repose,  comfort,  and  ready  adaptation  ; here  they  are  not  bound  to 
any  effort,  either  intellectual  or  moral.  Alcohol,  lewd  and  designing 
women,  complete  the  picture. 

Tonnini,  in  a communication  to  the  congress  of  the  Italian 
phreniatrists  held  at  Rome  in  1894,  spoke  of  social  imbeciles  corre- 
sponding to  those  I have  just  described  ; and  Venturi,  in  the  last 
booklet  he  published  before  his  death,  expressed  very  truly  the  idea 
that,  in  proportion  as  the  human  understanding  evolves  and  culture 
advances,  many  remain  behind  in  the  forward  movement  for  which 
the  strong  prepare  themselves,  in  order  to  attain  the  advantages 
that  civil  progress  offers  them.  They  are  the  weaklings  who,  in 
their  individual  and  sometimes  even  in  their  family  history,  do  not 


PH  REN  A STHE  NE\ 


443 


reach  the  normal  level  of  the  culture-curve  of  the  epoch  ; or  if, 
indeed,  the  family  attains  to  a normal  height,  it  soon  descends  again 
by  the  path  of  degeneration.  Primitive  or  degenerate,  they  are  weak 
in  comparison  with  society  animated  by  the  cultured  spirit  of  the 
dme. 

To  the  gradations  of  intellect  correspond,  in  a certain  manner, 
gradations  of  speech.  In  this  study  we  may  retrace  the  whole  history 
of  the  development  of  language.  Idiocy  permits  us  to  detect  all 
the  regressive  formations  of  speech,  in  a manner  somewhat  corre- 
sponding to  the  evolutionary  formations  of  language  of  the  modern 
infant  [vide  ante).  In  imbecility  (if  we  wish  to  hold  to  the  dis- 
tinction previously  mentioned),  we  may  meet  with  all  the  gradations 
of  the  linguistic  patrimony  corresponding  to  the  evolution  of  thought 
and  wealth  of  language  in  humanity  and  the  modern  child, 
gradations  which  find  their  counterparts  in  the  primitive  character 
of  the  thought  and  language  of  those  who  have  always  lived  in  the 
country;  in  idiocy,  on  the  other  hand,  we  find  regressive  gradations, 
even  in  the  structure  of  the  word,  down  to  the  absolute  incapacity 
to  pronounce,  it  may  be,  even  a single  articulate  sound,  or  down 
to  the  simplest  expression  of  the  primitive  emotions,  most  fre- 
quently very  obscure,  with  an  inarticulate  vowel-sound  which 
varies  in  different  idiots  from  the  feline  mew  to  the  amorous 
jabbering  of  the  ciasma  cynocefhalus.  Even  when  they  possess 
a rudiment  of  language,  idiots  mar  long  words  of  three  or  four 
syllables,  because  the  very  simple  structure  of  their  nervous  system 
does  not  allow  as  extensive  and  complex  a co-ordination  of 
combined  movements  as  that  which  a long  word  necessitates. 

They,  like  infants,  simplify  the  sounds  and  abbreviate  the  words. 
One  idiot  among  the  number  examined  by  me  did  not  say  tavolino, 
even  when  I studiously  repeated  the  word  to  him,  but  talin  ; instead 
of  patata  he  said  tata  ; acco  for  alhicocco  ; li-li  for  lihro,  etc.  Others 
are  capable  of  pronouncing  only  one  syllable  of  the  word,  the  easiest 
or  the  most  accentuated — pa  for  pane  ; vi  for  vino  ; he  for  here  , to 
for  dottore.  Sometimes  with  a great  effort  and  with  long  education, 
perchance,  they  become  able  to  add  another  syllable  to  the  mono- 
syllable. One  idiot  who  had  learnt  to  recognise  the  doctors  and  to 
assign  to  them  the  word  dottore  (doctor),  although  he  was  incapable 
of  distinguishing  one  doctor  from  another  and  the  superintendent 
from  the  assistants,  was  able  after  a long  time  to  pronounce  dotto  , 
thus  he  was  able  with  continuous  exercise  to  form  a small  capital  of 
bisyllabic  words,  which  he  pronounced,  as  a rule,  in  association  with 
images  of  objects  and  persons. 

The  same  long  gradation  that  we  have  met  with  in  the  evolution 
of  thought  exists  in  the  evolution  of  language,  in  such  a way  that, 
with  respect  to  normal  language,  idiots  and  imbeciles  present,  in 
addition  to  the  poverty  of  their  vocabulary,  corruptions  in  the 
formation  of  the  word,  which  in  all  cases  are  a proof  of  a defect  of 


444 


PSYCHIATRY 


development  not  only  of  the  central  but  sometimes  also  of  the 
peripheral  organs — throat,  mouth,  lips,  tongue,  in  the  structure 
of  which  lies  a defect  of  that  harmonic  co-ordination  which  a 
function  so  delicate  and  complex  as  that  of  language  demands. 

Occasionally,  and  more  especially  in  imbeciles,  language  as  an 
outward  expression  is  well  developed,  so  that  they  pronounce  all 
words  perfectly  well,  but  sometimes  do  not  know  their  signification. 

This  holds  good  more  particularly  for  words  denoting  an  abstrac- 
tion, of  which  they  understand  nothing,  and  in  the  pronunciation 
of  which  they  find  merely  a phonic  or  senso-muscular  satisfaction  ; 
or  they  associate  therewith  a simple  concrete  image,  sometimes 
even  very  different  from  those  that  as  a rule  constitute  the  abstract 
idea.  Hence  it  arises  that  the  language  employed  by  some  imbeciles 
is  not  only  meagre,  but  also  wanting  in  precision. 

From  an  anthropological  point  of  view,  idiots  more  especially, 
imbeciles  in  a rather  less  degree,  present  all,  or  a conspicuous  number 
of,  those  degenerative  stigmata  which  I have  briefly  indicated  in 
the  preceding  chapter,  and  which  I do  not  deem  opportune  to 
repeat  at  this  point. 

I cannot,  however,  entirely  neglect  to  mention  here  those  that 
are  most  frequent,  and  some  almost  characteristic  ; thus,  micro- 
cephaly, hydrocephaly,  ultradolichocephaly,  unilateral  or  bilateral  ' 
microphthalmia,  albinism,  blindness  from  pigmentary  retinitis  ; 
and  opticatrophy,  deaf-mutism  from  atrophy  of  the  acoustic 
nerves,  anorchism,  monorchism,  rudimentary  or  undescended  ’ 
testicles,  too  small  or  very  large  penis,  epi-  or  hypo-spadias,  atrophic  ^ 
uterus,  vaginal  septum,  hermaphroditism,  polydactylism,  and 
rudimentary  hand,  all  anomalies  denoting  a defect  of  evolution  not 
only  of  the  brain,  but  also  of  the  entire  organism,  and  especially  ; 
of  the  sexual  apparatus,  as  well  as  that  of  the  nervous  system.  ( 

As  regards  disturbances  of  the  sensory,  motor,  and  reflex  spheres,  1 
there  are  recorded  deafness,  blindness  (Ireland’s  phrenasthenia  • 
from  deprivation),  motor  paralysis,  hemiplegia,  diplegia,  para-  ^ 
plegia,  with  increase  of  the  tendon  reflexes ; progressive  myopathies ; 
often  a certain  muscular  hypertonicity.  Save  for  the  increase  of 
the  deep  reflexes  in  the  paralytic  phrenasthenics,  these  phenomena 
present  no  appreciable  alteration. 

Instead  of  giving  more  particular  descriptions  of  such  morbid 
forms,  it  is  preferable  to  report  some  cases  observed  in  the  asylum,  ! 
amongst  which  I have  selected  a microcephalic,  an  epileptic,  and 
a paralytic  idiot,  representing  three  great  groups  of  this  numerous 
family  of  degenerates. 

Observation  I.  : Idiocy  and  Profound  Microcephaly. — San.  R., 
admitted  November  22,  1897.  He  has  one  sister,  also  microcephalic, 
Init  not  an  idiot  to  the  same  marked  extent.  No  family  history. 


PHRENASTHENIA 


445 


Anthropoinetry.—Ueight,  1-34  metres;  large  aperture  of  the  arms, 
1-41  metres;  circumference  of  the  thorax,  o-8i  metre;  length  of  the 
sternum,  0’i45  metre  ; length  of  the  abdomen,  0*245  metre  ; bisiliac 
diameter,  0*130  metre  ; right  half  of  thorax  more  developed  than  the 
left  ; from  the  median  line  of  the  sternum  to  the  spinous  apophyses  of 
the  dorsal  vertebra,  passing  immediately  below  the  mammary  nipple, 
on  the  right  side,  0*410  metre  ; on  the  left,  0*390  metre.  Marked  lordosis 
in  the  dorsal  portion  of  the  vertebral  column.  Inability  to  completely 
extend  the  arms  in  crucifixion  attitude.  Great  development  of  the  two 
acromion  processes  of  the  scapulae,  impeding  the  complete  upward 
movement  of  the  two  arms. 

Cranium. — Dia.  ant.  post,  max.,  149  millimetres.  Dia.  trans.  max., 
107  millimetres.  Med.  long,  curve,  223  millimetres.  Trans,  curve, 

213  millimetres.  Total  circum.,  440  millimetres.  Ant.  semi,  curve, 

217  millimetres.  Post.  semi,  curve,  223  millimetres.  Sum  of  the  three 
curves,  876  millimetres.  Right  lateral  semi,  curve,  215  millimetres. 
Left  lat.  semi,  curve,  225  millimetres.  Height  of  forehead  (very  de- 
pressed), 48  millimetres.  Dia.  front,  min.,  85  millimetres.  Dia.  bizyg., 

105  millimetres.  Height  of  face,  107  millimetres.  Cephalic  index, 

71*88  millimetres. 

The  cranium  is  very  small  as  compared  with  the  face,  which  is  rela- 
tively very  large.  It  may  be  said  that  the  frontal  part  of  the  cranium  is 
completely  wanting,  for  it  is  so  flattened  that  the  frontal  bone,  retreating 
abruptly,  seems  to  form  a very  acute  angle  with  the  base  of  the  cranium. 
Ears  small,  pinna  flattened,  Darwin’s  tubercle  present,  and  lobules 
adherent  ; the  left  situated  at  a lower  level  than  the  right.  Nose  large, 
and  very  broad  at  the  base.  The  palpebral  fissures  are  directed  down- 
wards and  inwards.  Teeth  irregular  and  asymmetrical,  temporal  muscles 
very  highly  developed.  The  scalp  has  a decidedly  pachydermatous 
character  ; absence  of  hair  on  the  chest  ; mammary  nipples  well  de- 
veloped ; penis  large,  prepuce  large  and  long.  The  left  testicle  alone  has 
descended  into  the  scrotum.  General  sensibility  is  torpid.  He  does  not 
react  to  slight  tactile  stimuli  ; to  painful  stimuli  he  does,  but  the  threshold 
of  pain  is  evidently  far  removed  from  the  normal.  He  is  afraid  of  the 
noise  of  the  tuning-fork  brought  close  to  his  ear  ; he  is  pleased  with  the 
tick-tack  of  a watch,  which  he  at  once  puts  to  his  ear  if  he  is  given  it 
in  his  hands.  It  has  been  impossible  to  ascertain  to  what  extent  he 
can  distinguish  colours.  Taste  and  smell  appeared  quite  rudimentary. 

Cutaneous  reflexes  are  normal,  so  also  is  the  conjunctival  reflex. 
Those  of  the  auditory  canal  and  the  Schneiderian  membrane  are  sluggish. 
Patellar  reflexes  are  somewhat  increased  on  both  sides. 

Motility. — He  walks  with  slow  steps,  with  the  trunk  inclined  forwards 
and  the  body  curved.  He  moves  as  one  piece,  without  elasticity  or 
suppleness  of  person.  He  is  always  torpid  under  any  stimulus  whatever  ; 
always  slow,  inefficient,  and  awkward.  He  is  fond  of  smoking  ; if  he  is 
given  a lighted  cigar,  he  puts  it  in  his  mouth,  imitates  the  usual  move- 
ments of  the  lips,  and  assumes  a certain  stupidly  pretentious  air,  but  he 
does  not  know  how  to  co-ordinate  the  movements  for  the  aspiration  of 
the  smoke,  at  which  he  makes  ridiculous  attempts.  If,  again,  he  is  given  a 
box  of  matches,  after  several  attempts  he  succeeds  in  opening  it,  but 
takes  a long  time  to  get  hold  of  a match  between  his  fingers,  does  not  then 
know  how  to  ignite  it,  and  ends  by  offering  the  match  to  another,  making 
signs  to  him  to  do  it  ; and  if  he  is  given  the  match  lighted  it  is  easier  for 
him  to  burn  himself  than  to  light  the  cigar.  A certain  resistance  of  the 
voluntary  muscles  to  passive  movements  is  noted,  especially  in  the  upper 
limbs. 

Physiognomy. — Vacuous  and  stupid.  Occasionally  he  smiles,  never 
does  he  weep.  He  perceives  objects  in  common  use,  but  very  many  things 


446 


PSYCHIATRY 


pass  under  his  senses  unobserved  ; he  gives  no  sign  of  having  noticed 
them.  He  orientates  himself  in  space,  for  he  moves  with  some  deter- 
mined object,  and  even  so  far  as  displays  the  recognition  of  objects 
referring  most  immediately  to  his  needs.  For  example,  he  recognises 
foodstufts,  and  up  to  a certain  point  is  able  to  select  from  amongst  them 
those  of  which  the  flavour  appeals  to  him  most,  and  which  he  always 
prefers.  When  the  differences  between  two  objects  are  not  very  evident, 
he  is  incapable  of  distinguishing  them — e.g.,  after  having  eaten  a piece  of 
sugar,  he  puts  in  his  mouth  a piece  of  chalk,  and  does  not  spit  it  out  until 
after  he  has  ground  it  with  his  teeth.  If  various  objects  are  placed 
before  him  on  the  table — a halfpenny,  a key,  a watch,  a small  mirror — 
he  does  not  concern  himself  with  the  bright  objects,  as  might  be 
expected,  but  invariably  runs  straight  for  the  money  with  outstretched 
hand.  Money  must  certainly  reawaken  in  his  mind  the  memory  of  the 
satisfactions  which  it  had  been  able  to  obtain. 

As  is  evident,  the  attention  is  extremely  weak.  The  sensory  attention 
is  limited  and  confined  to  a few  things  ; it  is  impossible  to  speak  of 
voluntary  attention  : that  is  entirely  wanting.  Almost  nothing  is 
capable  of  arousing  his  interest,  excepting  perhaps  money,  watches,  and 
certain  fruits.  He  may  be  made  to  hear  the  most  varied  sounds,  to  see 
the  most  varied  colours  ; he  may  be  confronted  with  objects  that  very 
readily  excite  infantile  curiosity  without  manifesting  by  voice  or  physiog- 
nomy any  sentiment  whatsoever,  or  any  desire,  be  it  ever  so  weak,  of 
obtaining  possession  of  them.  He  takes  a firm  hold  of  objects  placed  in 
his  hands,  but  if  deprived  of  them  displays  the  utmost  indifference.  I 
do  not  recollect  any  cry  of  displeasure  or  of  rage. 

The  psychic  activity  is  almost  exclusively  limited  to  ideas  and  desires 
relative  to  food.  Mechanically,  monotonously,  he  repeats  his  habitual 
refrain — accompanying  it  with  a gesture  of  the  hand,  as  of  a person 
imploring — ‘ Give  me  some  bread.’ 

The  altruistic  affective  sphere  is  completely  obliterated.  There  pre- 
dominates only  a certain  egoism  which  is  translated  into  the  persistent 
demands,  accompanied  by  cadenced  moans,  that  are  the  expression  of  the 
stimulus  of  the  desire  to  eat.  The  entire  emotivity  of  this  subject  is 
reduced  to  the  most  elementary  expressions  of  pleasure  and  of  pain. 
When  he  is  given  anything  that  pleases  him,  or  when  any  nurse  who  takes 
a more  than  usual  interest  in  him  approaches,  his  physiognomy,  as  a 
rule  stupid  and  immobile,  gives  an  indication  of  a smile  in  outline,  as  it 
were,  but  it  does  not  manage  to  make  itself  evident  as  in  the  normal 
individual.  He  also  employs  some  guttural  sounds  that  resemble  grunts 
to  express  a certain  feeling  of  contentment  by  which  he  is  dominated 
under  certain  circumstances.  Again,  from  time  to  time,  at  longer  or 
shorter  intervals,  days  or  weeks,  he  suffers  from  attacks  of  bad  temper, 
manifested  by  louder  and  longer  groans  and  by  attempts  to  bite  his  arms 
and  hands,  to  tear  his  clothing,  especially  those  parts  of  it  he  manages  to 
get  hold  of  with  his  teeth,  and,  if  he  happens  to  be  eating,  by  throwing 
away  his  bowl  and  spoon.  Sometimes  these  impulses  are  provoked  by 
excessive  annoyance  caused  by  other  impertinent  patients,  but  as  a rule 
they  are  without  apparent  cause,  without  evident  external  stimuli. 
Very  probably  he  expresses  in  this  manner  the  somatic  disturbances  that 
he  cannot  otherwise  manifest  ; they  may  be  regarded  as  the  reflex  of  the 
abnormal  centripetal  waves  issuing  from  one  or  other  of  his  organs, 
seeing  that  it  is  not  possible  to  attribute  to  them  any  ideative  repre- 
sentation, however  elementary. 

It  is  possible  to  note  a certain  expression  of  pain  when  his  food  is 
taken  from  him  whilst  he  is  eating  and  still  very  hungry.  For  the  rest, 
one  may  take  away  the  halfpenny  of  which  he  has  obtained  possession 
or  remove  the  cigar  from  his  mouth  whilst  he  is  smoking  without  his. 


PHRENASTHENIA 


447 


making  any  complaint.  Not  infrequently  he  falls  asleep  in  his  chair 
or  remains  motionless  for  many  hours. 

The  phonic  manifestations  are  reduced  to  mere  groans  and  a few 
articulate  sounds — in  fact,  almost  exclusively  to  no,  u,  pa — by  which  he 
expresses  alike  his  desire  for  food  and  his  request  for  a halfpenny.  He 
appears  to  say  vo  he  when  he  is  thirsty. 

He  eats  voraciously,  using  his  fingers  ; often,  if  not  watched,  he 
devours  such  a quantity  of  food  that  he  ends  by  vomiting.  No  sign  of 
awakening  of  sexual  life  ; no  epileptic  attack. 

Observation  II. : Idiocy  with  Infantile  Spastic  Hemiplegia  and- 
Epilepsy. — D’  Ang.  Carm.,  from  Q.  (admitted  to  the  wards  February  23, 
1896).  Paternal  grandfather  and  grandmother,  as  also  maternal  grand- 
father, died  of  acute  diseases  ; maternal  grandmother  still  enjoys  good 
health  at  a very  advanced  age.  Father  and  mother  of  very  limited 
intellectual  development.  The  mother  is  affected  with  goitre,  but  not  in 
a marked  degree  ; she  frequently  suffers  from  faecal  stagnation,  and  often 
so  severely  as  to  be  confined  to  bed,  sometimes  for  a whole  month.  She 
is  keenly  sensitive,  as  she  says,  to  moral  impressions,  especially  if  un- 
pleasant ; at  such  times,  in  fact,  she  is  thrown  into  an  almost  convulsive 
condition,  in  which  her  whole  person  trembles  and  her  teeth  chatter,  as 
though  overwhelmed  by  an  intense  feeling  of  cold.  The  father  is  a well- 
doing, industrious  man,  fond  of  his  family,  incapable  of  saying  a word 
not  perfectly  correct,  attached  to  the  Church,  and  very  devoted  to  the 
saints.  Of  eight  sons,  two  died  at  an  early  age  from  acute  affections  ; 
all  the  others  are  well.  One  of  them  it  has  been  possible  to  see,  and  he 
also  has  a goitre,  not  well  developed.  It  must  be  mentioned,  however, 
that  in  Q.  the  persons  suffering  from  this  affection  are  very  numerous. 
The  patient  was  healthy  until  eleven  months  old,  when  the  mother  one 
day  noticed  a swelling  in  the  infant’s  neck.  At  the  same  time  violent 
convulsive  attacks  supervened,  during  which  the  head  and  eyes  were 
turned  markedly  to  the  right  side.  It  is  not  known  if  fever  was  present, 
but  it  is  certain  that  hypodermic  injections  were  administered  by  the 
physicians,  though  it  cannot  be  said  what  drug  was  employed.  During 
the  convulsions  the  patient  had  vomiting  and  involuntary  passage  of 
faeces.  He  remained  hemiplegic  on  the  right  side.  From  that  time 
forward  the  patient  has  been  seized  with  convulsive  attacks  of  the  same 
nature  every  two  or  three  months,  these  being  frequently  preceded  by 
an  intense  feeling  of  cold.  The  duration  of  the  attacks  is  from  half  an 
hour  to  six  hours.  There  follows  invariably  a longer  or  shorter  period  of 
drowsiness  and  then  of  depression. 

He  has  always  been  of  a savage,  violent,  and  impulsive  nature.  It 
was  sufficient  to  interpose  an  obstacle  in  the  way  of  any  of  his  actions 
to  see  him  react  in  the  most  violent  manner.  Even  his  father  failed  to 
restrain  him,  for  he  offered  resistance  to  him  also,  and  if  he  saw  that  he 
was  not  going  to  have  the  upper  hand  at  close  quarters,  he  settled  the 
matter  by  retiring  to  a distance  and  throwing  stones  at  him.  He  had  no 
sense  of  shame  ; in  his  home  he  was  a continual  source  of  scandal  to  his 
sisters,  before  whom  he  fulfilled  his  needs  with  the  utmost  indifference. 
Having  thus  become  the  terror  of  the  neighbourhood  and  the  torment 
of  his  family,  his  parents  decided  to  have  him  sent  to  the  asylum. 

Cranium. — Diam.  ant.  post,  max.,  173  millimetres.  Diam.  trans. 
max.,  136  millimetres.  Cephalic  index,  78-61  millimetres.  Median  long, 
curve,  332  millimetres.  Transverse  curve,  265  millimetres.  Total  cir- 
cum.,  498  millimetres.  Ant.  semi,  curve,  235  millimetres.  Post.  semi, 
curve,  263  millimetres.  Right  lat.  semi,  curve,  229  millimetres.  Left 
lat.  semi,  curve,  269  millimetres.  Height  of  forehead,  43  millimetres. 
Diam.  front,  min.,  100  millimetres.  Diam.  bizygomat.,  107  millimetres. 
Height  of  face,  115  millimetres.  Facial  angle,  68  millimetres. 


448 


PSYCHIATRY 


Degenerative  Anthropological  Characters.  — Microcephaly,  scapho- 
cephaly, plagiocephaly  ; forehead  low,  narrow,  receding  ; occiput  flat  ; 
eyes  sunk  deeply  (the  ocular  bulb  seems  somewhat  diminished),  slight 
convergent  strabismus.  Plagioprosopia  : zygomata  highly  projecting  ; 
asymmetrical  lop-ears  set  at  different  levels,  the  right  being  the  lower  ; 
very  marked  development  of  the  penis. 

The  entire  right  half  of  the  body  at  the  very  first  glance  seems  much 
less  developed  than  the  left.  Not  only  the  muscular  system,  but  also  the 
skeletal  part  is  affected.  The  following  measurements  reveal  the  degree 
of  shortening  of  the  bones  : 

1.  Distance  from  the  top  of  the  acromion  to  the  top  of  the  epicondyle 
on  right  side,  280  millimetres  ; on  left,  290  millimetres. 

2.  Distance  from  the  upper  extremity  of  the  elbow  to  the  tip  of  the 
styloid  apophysis  of  the  radius  on  the  right  side,  250  millimetres  ; on  the 
left,  290  millimetres. 

3.  Distance  from  the  styloid  apophysis  of  the  elbow  to  the  top  of  the 
middle  finger  on  the  right  side,  155  millimetres  ; on  the  left,  183  milli- 
metres. 

4.  Distance  from  the  top  of  the  great  trochanter  to  the  external  epicon- 
dyle of  the  femur  on  the  right  side,  350  millimetres  ; on  the  left,  350 
millimetres. 

5.  Distance  from  the  upper  extremity  of  the  fibula  to  the  top  of  the 
external  malleolus  on  the  right  side,  353  millimetres  ; on  the  left,  395 
millimetres. 

The  measure  of  the  circumference,  taken  in  the  most  prominent 
points,  gives  the  following  results  : Right  arm,  182  millimetres  ; left  arm, 
220  millimetres  ; right  forearm,  190  milhmetres ; left  forearm,  210 
millimetres  ; right  thigh,  370  millimetres  ; left  thigh,  395  millimetres  ; 
right  leg,  240  millimetres  ; left  leg,  255  millimetres. 

Tactile  sensibility  on  the  left  side  is  normal,  but  the  localization  of 
stimuli  is  under  normal,  being  made  with  a certain  tardiness.  This 
defect  is  much  more  evident  on  the  paralyzed  side. 

Only  marked  thermic  differences  are  appreciated.  The  sense  of  pain 
is  diminished,  more  particularly  on  the  right  side.  The  muscular  sense 
is  diminished  on  the  paralyzed  side  ; with  the  eyes  closed,  he  executes 
fairly  delicate  movements  with  the  upper  and  lower  limbs  on  the  left  side  ; 
the  movements  of  the  corresponding  parts  on  the  right  side  are  not  so 
precise. 

The  various  pleasant  and  unpleasant  odours  are  not  differentiated. 

Sweetness  is  distinguished  exactly ; the  other  three  fundamental 
tastes  (acid,  salt,  bitter)  are  all  regarded  as  bitter. 

The  plantar  reflex  is  a little  sluggish.  The  cremasteric  reflex  is  more 
easily  elicited  on  the  left  side  ; the  abdominal  and  the  axillary  are  veiy 
pronounced. 

The  pupillary  reflexes  are  sluggish.  The  patellar  reflex,  the  reflexes 
of  the  tendon  of  Achilles,  the  flexor  muscles  of  the  hand,  the  triceps 
extensor  of  the  forearm,  and  the  periosteal  reflexes,  are  somewhat  more 
pronounced  on  the  right  side.  On  this  side  also  the  foot  phenomenon 
can  be  obtained. 

Gait  limping.  In  the  act  of  walking,  the  right  foot  is  raised  very 
high  (resulting  from  the  greater  development  of  the  left  lower  limb),  is 
thrust  outwards,  then  brought  inwards,  as  if  he  wished  to  execute  a 
sickle-like  movement,  and  finally  put  down  lather  vigorously  on  the 
ground. 

Convergent  strabismus.  The  movement  of  the  ocular  bulb  to  the 
left  side  is  incomplete,  or,  if  performed,  is  maintained  only  for  a moment. 
Movement  towards  the  right  side  is  mere  sustained.  The  ocular  move- 
ments upwards  and  downwards  are  normal. 


PHRENASTHENIA 


449 


All  the  combinations  of  attitude. and  of  physiognomy  that  reveal  the 
various  states  of  mind  are  in  him  sought  for  in  vain.  His  facial  features 
are  dull  and  listless.  In  his  ordinary  state  the  eyes  are  inexpressive,  the 
lips  half  open,  the  cheeks  wrinkled  or  flaccid.  Sometimes  thick  and 
viscid  saliva  trickles  from  his  mouth  (this  seems  to  depend  partly  on  the 
abundance  of  the  secretion)  ; mucus  flows  from  his  nose,  but  he  never 
thinks  for  a moment  of  wiping  it.  _ 

The  movements  of  both  upper  and  lower  limbs  on  the  right  side  are 
incomplete  ; athetosis  is  present.  ^ 

The  muscles  of  the  arm  and  of  the  forearm  react  to  the  faradic  current,, 
but  on  the  left  side  in  a slightly  lower  degree. 

Force  on  the  left  side,  35  ; on  the  right  side  he  cannot  displace  the 
index  of  the  manometer.  The  muscular  force  in  both  flexors  and  ex* 


tensors  of  the  forearm  on  the  arm,  and  of  the  leg  on  the  thigh,  is  markedly 
diminished  on  the  right  side — in  the  upper  limb  to  a greater  extent  than 
in  the  lower.  _ '‘I 

Psychic  Functions. — The  patient  recognises  many  of  the  objects  in 
common  use,  and,  if  sometimes  unable  to  indicate  them  by  name,  shows, 
nevertheless,  that  he  understands  clearly  the  purpose  they  serve  ; it  is 
precisely  on  this  account  that,  when  he  fails  to  remember  the  name  of  any 
object,  he  often  employs  a roundabout  form  of  speech,  and,  e.g.,  Calls 
spectacles  ‘ the  things  for  the  eyes.’  At  other  times,  when*  the  percep- 
tions are  a little  more  complex,  he  is  capable  of  gathering  only  some  of 
the  features,  and  hence  arise  incomplete  and  erroneous  judgments  ; thus, 
a pen  becomes  a stick,  the  inkstand  a little  bottle.  For  a like  reason,  being 
incapable  of  discerning  the  points  of  difference  of  similar  objects — those 
which  serve  to  distinguish  them  from  one  another — he  generalizes,  and 
a coin  of  five  or  ten  centimes,  or  the  nickel  coin  of  twenty  centimes,  or  the 
silver  one  of  one  lira,  are  all  indifferently  soldi  to  him.  He  recognises, 
however,  the  two-centime  piece,  perhaps  because  the  children  of  the 
lower  classes  are  wont  to  be  possessed  of  that  money. 

Spontaneous  attention  is  always  very  poor  ; there  is  no  truly  active 
and  voluntary  direction  of  it.  He  is  capable  of  remaining  for  whole 
hours  with  vacant  countenance,  either  in  bed  or  seated  always  in  the 


Fig.  63. — Idiot  with  Infantile 
Spastic  Hemiplegia. 


Fig.  64. — Another  Hemiplegic 
Idiot. 


29 


450 


PSYCHIATRY 


same  position,  merely  turning  his  face  from  time  to  time  to  one  side  or 
the  other,  evincing  no  curiosity  or  any  interest  in  the  external  world. 

If  haply  some  object  comes  under  his  observation,  he  often  brings 
himself  to  contemplate  and  recontemplate  it  as  one  enchanted  ; some- 
times he  takes  it  into  his  hands,  but,  after  having  turned  it  over  several 
times,  abandons  it,  either  to  resume  his  accustomed  attitude  or  to  set 
himself  to  contemplate  some  other  thing.  He  evinces  greater  curiosity 
and  greater  interest  in  any  object  that  stimulates  his  senses  more  vividly 
than  another.  Thus,  the  tuning-fork  has  commanded  his  attention  so 
far  as  to  induce  him  to ‘take  hold  of  it,  to  put  it  close  to  his  ear,  and  to 
manifest,  by  his  face  and  his  speech,  his  great  wonder  when  the  vibrations 
have  died  away. 

The  mnesic  field  is  very  much  restricted.  On  interrogating  him  on 
every  point  and  by  every  means,  that  which  most  readily  comes  up  again 
in  his  conversation  (which,  on  the  other  hand,  is  not  easily  understood 
on  account  of  marked  defects  in  language)  is  the  recollection  of  some  of 
his  country  habitudes,  and  nothing  else. 

Indeed,  he  remembers  only  his  Christian  name,  and  is  ignorant  of  his 
proper  surname  ; he  can  tell  the  name  of  his  country,  but  does  not  know 
the  name  of  his  father  or  mother,  who  by  him  are  called  simply  tatta 
and  maynma. 

He  has  learned  the  names  of  the  numbers,  but  repeats  them  mechani- 
cally and  without  order,  since  he  does  not  understand  their  value,  as  may 
readily  be  shown.  Thus,  on  showing  him  some  soldi  and  inviting  him 
to  count  them,  he  commences  indifferently  at  3,  5,  or  8,  proceeding 
capriciously,  let  us  suppose  (as  on  one  occasion  he  did),  to  25,  6,  8,  14,  12, 
10,  50,  45,  and  so  on.  On  suggesting  to  him  the  first  number  i,  he 
proceeds  well  enough  up  to  9,  but  on  going  further  he  begins  to  get  con- 
fused. He  is  unable,  of  course,  to  tell  how  many  fingers  or  how  many 
coins  are  shown  to  him  at  a time. 

The  ideative  content  is  very  meagre.  Ideas,  besides  being  extremely 
limited  in  number,  are  simple  and  incomplete,  showing  no  connection  with 
one  another.  There  is  no  spontaneity  of  thought ; he  does  not  utter  a 
single  word  unless  when  interrogated,  and  he  will  stand  mute  before  one 
for  any  length  of  time.  Further,  his  vocabulary  is  extremely  restricted. 
One  by  one,  he  pronounces  well  all  the  letters  of  the  alphabet  (the  sound 
of  /,  however,  approaches  to  that  of  r ; the  pronunciation  of  d closely 
resembles  that  of  t),  but  in  the  union  of  the  different  syllables  whence 
results  a word,  the  latter  is  more  or  less  markedly  faulty  in  structure,  the 
more  so  the  more  complex  the  word  is.  Of  these  we  transcribe  a few  , 
examples  ; hacio  is  pronounced  correctly  ; pane — pa,  pan,  payide,  nde  ; 
gatto — catto,  tatto,  to  ; chiave — chiade,  ngfe,  and  finally  chiave  ; portogallo 
— cardo,  cattido,  potnga-l-lo,  pot-ugal ; capello — cappeldo,  catpelo,  cappello  ; i 
storia — stor,  slipping  the  a little  ; sedia — seda  ; memoria — holla,  hollo, 
niello,  hor-YO  (slipping  the  r)  ; tavola — ta-lo  ; callo — calo,  cavo,  cadevo  ; 
mano — ma-mo,  mo  ; orribilmente — oh-mente-orrepe,  or  else  an  irrepro- 
ducible  sound  ; zucchero — zucche,  zucqne. 

The  sentiments  are  reduced  to  the  lowest  and  most  egoistic  that  are 
directly  connected  with  satisfaction  of  the  instinct.  He  shows  no 
affection  for  the  persons  who  come  most  in  contact  with  him. 

If  sometimes  an  accession  of  sympathy  is  awakened  in  him,  he  is 
unable  to  show  it  except  in  the  most  primitive  manner,  leaping  upon  one,  ^ 
pawing  one  over,  clutching  one’s  clothes  so  as  almost  to  tear  them  off, 
grasping  one  by  the  hand  and  shaking  it  energetically,  accompanying  the 
actions  with  almost  convulsive  laughter,  which  at  bottom  is  reduced  to 
inspiratory  and  expiratory  yells.  The  sufferings  of  others  make  him 
happy  ; on  making,  in  front  of  him,  a pretence  of  striking  some  other 
person,  he  rejoices  and  smiles  thereat.  The  greatest  expression  of  satis- 


PHRENASTHENIA 


451 


faction  animates  his  face  when  he  is  reminded  of  the  scratches  he  made 
on  another  patient  who  held  him  tightly  whilst  he  was  being  examined 
with  the  faradic  current. 

He  is  then  animated  to  the  extent  of  not  being  able  to  refrain  from 
again  assuming  the  attitude  he  took  on  that  occasion,  presenting  the 
appearance  of  wishing  to  scratch,  and  laughing  loudly  the  while.  As  a 
rule,  he  passes  the  day  either  seated  carelessly  in  one  place,  or,  what 
pleases  him  more,  lying  at  full  length  in  bed,  indifferent  to  everything  and 
everybody.  His  presence  would  remain  unobserved  if  he  did  not  from 
time  to  time  call  attention  to  himself  by  giving  vent  to  yells  very  like 
the  bellowing  of  the  ox. 

Sleep  and  appetite  are  very  good. 

Observation  III.  : Imbecility. — Cam.  M.,  from  Giugliano  Cam- 
pania, aged  thirty-nine  ; unmarried,  domestic,  moderately  competent, 
hardly  able  to  read  and  write  ; admitted  to  clinique  November  12,  1894. 

The  father  appears  to  have  died  as  the  result  of  a traumatic  lesion. 
He  was  a well-doing,  credulous  man,  but  so  weak  in  character  as  to  be 
completely  under  the  control,  first  of  his  wife,  then  of  his  sons. 

The  mother  is  a woman  of  uncommon  and  sordid  avarice.  She  is 
alive  and  well.  She  has  had  a family  of  six. 

A paternal  and  a maternal  aunt  died  insane.  The  eldest  sister, 
though  perhaps  of  no  greater  mental  development  than  the  sons,  was  so 
persevering  and  artful  as  to  take  into  her  own  hands  the  reins  of  domestic 
management,  surpassing  the  mother  in  meanness  and  stinginess,  going 
the  length  of  depriving  her  poor  old  father  even  of  his  coffee  and  tobacco, 
obliging  him  to  smoke  dried  leaves. 

Another  married  sister  has  had  two  children,  one  of  whom  died  of 
eclampsia. 

She  has  three  brothers,  all  generally  of  limited  mental  development. 
One  of  them,  in  fact,  got  on  so  badly  at  school  that  he  could  not  be  got 
to  say  Mass  till  over  thirty  years  of  age. 

Our  patient  seems  to  have  gone  on  developing  regularly  till  her 
fourteenth  year,  but  as  she  became  older  her  intelligence  did  not  make 
corresponding  progress.  She  remained  the  childish  simpleton  that  she 
had  always  been  : dolls,  toys,  and  games  always  succeeded  in  attracting 
her. 

There  was  a time  when  her  relatives  entertained  thoughts  of  her 
marriage,  and  a young  man  desired  to  espouse  her.  But  after  a little 
time  he  perceived  what  type  of  woman  he  was  about  to  marry,  and  very 
soon  broke  all  agreements.  Her  parents  state  that  this  fact  made  a 
very  deep  impression  on  the  girl ; but  the  result  that  more  certainly  ensued 
was  that  from  that  time  forward,  although  not  abandoning  her  childish 
behaviour,  she  became  more  conceited,  announcing  to  persons  who  had 
no  desire  to  know  it  that  she  was  going  to  marry  now  one  person,  now 
another. 

Meantime  her  strange  conduct  was  not  intolerable,  and  she  went 
on  more  or  less  unobserved  up  to  a certain  age  ; as  she  advanced  in  years, 
she  commenced  to  attract  more  attention.  She  was  without  discipline, 
and  could  never  be  made  to  understand  that  what  she  was  doing  did  not 
well  become  a young  woman  of  her  age.  Every  opposition  to  any  caprice 
on  her  part  provoked  an  uproar.  There  was  no  gathering  of  boys  in 
which  she  did  not  take  part  ; no  person  died  but  she  went  to  attend  the 
funeral  services,  remaining  blissfully  enchanted  by  the  candles  and  the 
psalmody  of  the  priests  ; did  a marriage  take  place,  she  was  there  among 
the  wildest  boys  to  compete  with  them  in  gathering  the  confetti  thrown 
on  such  occasions,  according  to  the  customs  of  the  country.  She  learned 
to  work  well  at  sewing,  but  serious  occupations  had  certainly  no  attrac- 

29 — 2 


452 


PSYCHIATRY 


tions  for  her.  She  took  a delight  in,  and  had  an  affectionate  word  for, 
the  kitten  and  for  the  pup,  with  which  she  held  long  and  interminate 
conversations.  Shortly  before  she  was  admitted  to  the  asylum  her 
favourite  kitten  died,  and  she  conceived  the  strange  notion  of  arranging 
a funeral  for  it  in  every  detail,  and  had  it  carried  in  procession  through 
the  whole  countryside,  followed  by  a number  of  children  whom  she 
succeeded  in  bringing  together.  Too  late  did  her  friends  come  to  hear  of 
the  affair  (of  which  she  craftily  had  let  nothing  leak  out)  to  avoid  the 
laughter  and  derision  that  threatened  them  on  all  sides.  It  was  this  affair 
that  exceeded  the  limits  of  endurance  of  her  relatives,  and  induced  them, 
for  the  sake  of  their  future  peace  and  the  honour  of  their  house,  to  request 
her  admission  into  the  asylum. 

Cranium. — Diam.  ant.  post,  max.,  165  millimetres.  Diam.  trans, 
max.,  137  millimetres.  Cephalic  index,  83*03  millimetres.  Med.  long, 
curve,  295  millimetres.  Trans,  curve,  265  millimetres.  Total  circum.,, 
480  millimetres.  Ant.  semicurve,  230  millimetres.  Post,  semicurve, 

250  millimetres.  Sum  of  the  three  curves,  1,040  millinietres.  Height  of 
the  forehead,  52  millimetres.  Min.  front,  diam.,  92  millimetres.  Bizygo- 
matic diam.,  88  millimetres.  Height  of  the  face,  in  millimetres.  Facial 
angle,  74  millimetres. 

Stature  low  ; cranium  small. 

Plagiocephaly  (forehead  flattened  on  the  left  side)  ; forehead  small^ 
somewhat  receding  ; e^rs  implanted  unequally,  the  left  being  lower  ; 
some  abnormal  hairs,  particularly  on  the  outermost  parts  of  the  upper 
lip  ; dental  diastem  between  the  canine  and  the  first  molar  of  the  superior 
dental  arch  on  the  left  side. 

Tactile  and  thermic  sensibility  almost  normal.  Sensibility  to  pain  is 
altered;  punctures  with  pins,  though  sufficiently  deep,  do  not  provoke  * 
ready  reactions  on  the  part  of  the  patient.  The  algometric  tests  show  < 
the  threshold  of  pain  to  be  very  far  from  the  normal.  ! 

The  gustatory  and  olfactory  sensibilities  are  poorly  developed.  ^ 
Sweetness  is  not  distinguished  by  the  patient,  either  in  the  anterior  or  the-  ’ 
posterior  region  of  the  tongue,  when  the  solution  is  not  very  sweet ; if,  , 
however,  the  solution  is  saturated,  she  perceives  the  sweetness,  which  is 
more  strongly  felt  at  the  posterior  part  of  the  tongue.  Bitterness  is  also  . 
more  distinctly  perceived  towards  the  base  of  the  tongue.  Solution  of  . 
acetic  acid  is  hardly  perceived  at  all  posteriorly.  I 

The  patient  does  not  distinguish  the  various  odours,  but,  on  the  - 
other  hand,  many  of  the  unpleasant  odours  (such  as  that  of  a weak  | 
solution  of  ammonia,  of  illuminating  gas,  of  asafoetida)  are  regarded  by 
her  as  pleasant.  She  distinguishes  strong  colours,  but  not  the  shades  : ^ 
she  does  not  know  their  names  ; she  does  not  distinguish  violet.  f 

The  pupillary  reflexes  are  a little  sluggish  ; all  the  other  reflexes  are 
normal.  In  general,  all  the  motor  manifestations  are  somewhat  torpid  ; 
no  disturbances  in  the  general  motility. 

Force,  measured  by  the  dynamometer,  is  very  weak  : on  the  right,  15  ; 
on  the  left,  13.  She  is  evidently  incapable  of  volitional  efforts. 

Psychic  Functions. — The  perceptive  process  is  weak  ; all  the  ordinary 
and  common  perceptions  are  conserved,  but  the  same  cannot  be  said  of 
those  of  a higher  order.  For  example,  although  during  the  whole  day  she 
is  surrounded  by  persons  exclusively  of  her  own  sex  and  only  sees  the 
doctor  once  or  twice  in  the  day,  she  has  never  asked  who  he  is  nor  what 
he  comes  to  do.  On  asking  her,  she  at  first  expresses  a very  general  idea  : 

‘ You  are  a young  man  : you  are  a gentleman.’  On  persisting  in  the 
inquiry,  she  makes  still  another  distinction,  but  always  general  and  super- 
ficial. In  fact,  being  a country  girl,  the  first  distinction  that  comes  into 
her  mind  is  that  between  a Giuglianese  and  a Neapolitan  ; and,  as  she  has 
never  seen  the  doctor  in  Giugliano,  she  adds,  ‘ You  are  a Neapolitan.’ 


PHRENASTHENIA 


453 


After  many  insistences  and  demands,  she  decides  at  last  to  add,  ‘ You  are 
perhaps  a lawyer.’ 

Our  lady  superintendent,  whom  she  sees  also  many  times  a day,  is  a 
' Signora  ’ in  whose  room  the  ‘ mistresses  ’ meet  together  (for  so  she 
regards  a good  number  of  the  nurses).  Sensory  disturbances  of  any  kind 
have  never  been  observed  during  the  entire  period  of  her  residence  in  the 
asylum. 

Spontaneous  attention  is  fairly  active,  but  wanders  continually  from 
one  thing  to  another,  or  becomes  suddenly  distracted  by  other  stimuli 
or  images  recalled  by  new  perceptions,  through  frail  and  superficial 
associative  connections.  Provoked  attention  may  be  aroused  without 
much  difficulty  ; but  whenever  she  has  commenced  to  launch  out  her 
idle  chatter,  it  is  well-nigh  impossible  to  stop  her  at  once,  to  induce  her  to 
speak  in  an  ordinary  fashion  on  some  given  event,  or  to  make  her  change 
the  subject. 

The  memory  of  past  as  well  as  recent  events  is  faint,  summary,  and 
unprecise.  She  is  unable  to  tell  how  old  she  is  (she  states  she  is  twenty- 
seven,  while  in  reality  she  is  thirty-nine)  ; she  does  not  know  how  long 
she  has  been  in  the  asylum  (she  says  about  seven  months,  whilst  it  is  now 
over  fourteen)  ; she  has  not  yet  learned  the  names  of  the  nurses,  not  even 
of  those  in  her  w^ard  ; if  she  remembers  any  one  of  them,  it  is  because  she 
has  known  her  in  the  country,  and  has  been  familiar  with  her  from  her 
infancy.  She  has  not  acquired  a clear  idea  of  time.  The  events  that  she 
narrates  to  us  are  recounted  as  though  the  years  in  which  they  happened 
— even  approximately — were  of  no  importance.  Her  points  of  rendezvous 
are  not  indeed  the  months,  which  she  says  she  doesn’t  know,  nor  the  years, 
but  the  holidays  of  her  country  and  the  fruits  which  the  earth  gives  in 
determined  seasons.  For  example,  she  says,  ‘ I came  here  when  the  grape 
season  was  past.’ 

Spontaneous  ideation  is  facile,  but  disordered.  Associative  bonds 
are  unstable  and  superficial.  Ideas  are  not  well  defined,  often  erroneous  ; 
judgments  sometimes  false,  sometimes  strange,  always  superficial.  She  is 
exceedingly  credulous ; it  is  sufficient  to  tell  her  some  foolish  thing  in 
order  that  later  on  she  may  tell  it  over  again  in  the  most  solemn  manner. 
For  example,  she  says  at  present  that  she  is  not  the  daughter  of  her 
mother,  but  of  the  Madonna,  and  that  she  was  taken  from  the  shelter  of 
the  Virgin  Mary,  for  she  has  ‘ been  told  so.’  In  her  continuous  chatter 
there  is  a prevailing  manifestation  of  ideas  referring  either  to  her  own 
personality  or  reminiscent  of  all  the  things  she  possessed  when  at  home. 

A thousand  small  facts,  a thousand  useless  details,  a thousand  follies, 
she  intersperses  in  her  discourses.  ‘ Once  I was  beautiful  and  had  rosy 
cheeks.  I possessed  many  earrings,  wore  small  boots,  and  had  lots  of 
dresses  ; mamma  had  lots  of  money,  and  she  made  it  secretly  for  herself. 
I had  a lover,  and  he  was  so  beautiful  that  he  could  see  himself  in  a glass 
of  water  ; he  killed  thirty  pigs ; he  sold  cornelians  and  olives ; he  sold 
red,  white,  and  black  bread,  and  what  he  sold  nobody  else  succeeded  in 
selling  ; and  he  shut  the  shop  on  Sunday  ;’  and  so  on.  Finally,  the 
recollections  of  so  many  things  make  her  express  suddenly  this  strange 
longing,  ‘ How  I like  chestnuts  !’ 

The  sphere  of  the  highest  affections  gives  no  active  manifestations. 
She  never  goes  to  Mass  here,  because  ‘ our  chapel  is  not  worth  admiration.’ 

The  reminiscence  of  the  country  awakens  in  her  no  loved  memories  ; 
affection  is  not  stirred  by  the  image  of  her  mother  nor  the  recollection  of 
the  family ; it  is,  instead,  the  fetes  that  she  recalls — ‘ the  illuminated  streets, 
the  playing  of  the  bands,  the  firing  of  the  guns,  the  vendor  of  ices,  the 
church  all  flooded  with  light,  the  Madonna  with  the  heavenly  robes  and 
the  beautiful  eyes.’  It  matters  but  little  to  her  whether  her  relatives 
come  to  visit  her  or  not.  The  questions  she  puts  to  them  have  to  do, 


454 


PSYCHIATRY 


not  with  the  family,  but  the  cat,  the  reason  why  they  did  not  bring  her 
toys,  and  so  on.  On  the  contrary,  in  fact,  she  maintains  towards  her 
mother,  brothers,  and  sisters  a feeling  more  akin  to  hostility  than  anything 
else,  because  she  remembers  only  blows  and  reproofs  from  them.  Sexual 
desires  are  not  manifest. 

The  aesthetic  sentiment  is  rudimentary ; of  the  moral  sentiment 
nothing  can  be  said.  If  she  commits  no  wrongful  actions,  it  is 
because  of  the  absence  of  desire  or  of  the  representation  of  the  necessary 
images.  There  is  no  trace  of  true  inhibitory  power. 

Of  an  insuperably  lazy  character,  she  passes  the  whole  day  either  in 
blissful  idleness,  basking  in  the  heat  of  the  sun,  or  intent  in  taking  part, 
with  the  other  patients,  in  childish  pastimes,  passing  whole  hours  in 
playing  with  small  stones  or  with  pieces  of  linen,  paper,  and  so  on.  Nothing 
but  the  meal-hour  can  distract  her  from  her  favourite  occupations,  and 
then  she  makes  continual  complaints  that  her  portion  is  always  the 
smallest  and  the  worst  of  the  lot.  Nevertheless,  if  she  is  not  observed, 
in  a moment  afterwards  it  will  all  have  disappeared.  She  is  not  concerned 
about  her  lot — ‘ It  is  so  much  better  to  stay  here  than  at  home.’  Here 
she  enjoys  blissful  idleness,  the  garden,  and  the  sight  of  so  many  people  ; 
at  home  toil,  reproofs,  and  blows  are  her  portion.  Her  only  complaints 
are  that  she  has  been  deprived  of  the  toys  she  brought  with  her,  and  that 
she  never  gets  dishes  for  which  she  has  a preference. 

Appetite  very  good.  Sleep  always  good.  Occasional  dreams,  but 
of  no  importance. 

I have  purposely  included  here,  among  the  clinical  reports,  a 
case  of  pure  microcephalic  idiocy  with  infantile  spastic  hemiplegia, 
because  it  is  necessary  to  recognize  one  primary  distinction  of 
simple  phrenastheniacs  and  paralytic  phrenasthcniacs.  The  former, 
no  matter  what  the  degree  of  psychic  development  or  the  terato- 
logical  signs,  present  neither  sensory  nor  motor  paralyses  referable 
to  circumscribed  or  diffuse  lesions  of  the  nerve-centres  ; the  latter, 
however,  no  matter  what  the  defect  of  evolution  of  the  psychic  life, 
present,  in  addition,  motor  or  sensory  paralysis,  always  referable 
to  a limited  or  diffuse  anatomo-pathological  process  in  the  brain. 
These  cerebral  lesions,  as  we  shall  shortly  see,  are  of  the  most  varied 
nature  (hydrocephalus,  meningitis,  encephalitis,  sclerosis,  cerebral 
thrombosis,  cysts,  porencephaly,  etc.),  and  are  either  complications 
of  the  defective  evolution  of  the  brain  or  else  have  themselves  led 
to  an  arrest  of  cerebral  development  owing  to  the  consequent 
destruction  of  a more  or  less  extensive  and  important  part  of  the 
organ  of  thought,  and  to  the  functional  and  nutritional  disturbances 
induced  in  other  parts  of  the  cerebral  organ  that  have  functional 
and  anatomical  relations  with  the  part  destroyed. 

In  this  second  group  of  phrenasthenias,  in  addition  to  the 
general  symptomatology  relating  to  the  psychic  functions  and  the 
abnormal  psycho-somatic  evolution,  there  is  always  present  a group 
of  symptoms  produced  by  the  circumscribed  or  diffuse  cerebral 
disease.  Of  these  I shall  mention  only  the  most  frequent  and 
important — viz.,  hemiplegia,  paraplegia,  diplegia,  the  syndrome  of 
Little  (with  all  the  characteristics  of  the  cerebral  paralytic  forms 
and  the  long  train  of  phenomena  accompanying  them),  contractures, 


PHRENASTHENIA 


455 


symptomatic  chorea,  athetosis,  exaggeration  of  the  deep  reflexes 
(infantile  cerebroplegias),  strabismus,  atrophy  of  the  optic  papilla 
due  to  infiltration  of  fluid  into  the  sheath  of  the  optic  nerve  (hydro- 
cephalus, meningitis),  or  to  descending  degeneration  of  the  optic 
path  from  profound  lesions  of  the  occipital  lobes,  the  optic  thalami, 
and,  in  some  cases,  Friedreich’s  disease,  etc. 

In  the  majorit}^  of  these  cases  we  meet  with  another  important 
symptom,  viz.,  epilepsy.  Even  when  the  epileptic  convulsions  do 
not  accompany  and  complicate  the  symptomatology  of  the  diplegic 
phrenasthenias,  they  are  found  to  coincide  with  that  period  in  the 
history  of  the  illness  during  which  arose  the  anatomo-pathological 
process  that  complicated  or  generated  the  imperfect  and  anomalous 
development  of  the  brain.  Especially  is  there  found  a history  of 
inflammatory  processes,  the  various  forms  of  encephalitis  and 
meningitis,  in  the  symptomatology  of  which  we  almost  always  find 
eclampsia  (infantile  epilepsy),  which  may  henceforth  continue  as 
epilepsy  throughout  life,  or  remain  latent,  sometimes  for  a longer, 
sometimes  for  a shorter  time,  returning  again  in  childhood,  ado- 
lescence, or  maturity,  to  impress  its  stamp  on  the  already  miserable 
existence  of  the  phrenastheniacs.  Sometimes  the  epilepsy  is  recog- 
nisable only  in  the  moral  character  it  gives  to  the  psychic  life,  as 
we  shall  see  hereafter.* 

Still  one  other  form  of  idiocy  has  to  be  distinguished  from  the 
common  form  just  described — viz.,  myxcedematous  or  pachy dermic 
idiocy,  called  also  (in  my  opinion  improperly)  sporadic  cretinism. 
Myxcedematous  idiocy  is  a congenital  or  acquired  (always  infantile) 
form  of  myxoedema,  just  as  ordinary  idiocy  is  a congenital  or  infan- 
tile form  of  amentia.  It  is  observed  throughout  Europe  and  America. 
Whether  it  be  congenital  or  developed  after  birth,  the  clinical 
figure  appears  clearly  recognisable  between  the  second  and  sixth 
year.  Save  for  the  lips,  the  large  tongue,  the  relaxed  and  thickened 
skin,  and  a sort  of  fatty  swelling  in  the  neck,  the  affected  infants 
show  no  more  certain  signs  of  the  disease,  which  becomes  more 
pronounced  as  the  little  patient  advances  towards  childhood  and 
adolescence. 

When  the  disease  is  well  developed  the  appearance  is  charac- 
teristic. The  development  of  the  body  is  slow,  and  becomes 
arrested  before  reaching  the  normal  limit.  The  stature  is  low, 
the  body  thick-set  ; the  face  is  large,  and  seems  flattened  ; the 

* For  the  semeiological  particulars  of  the  infantile  cerebral  paralyses — 
hemiplegia,  diplegia,  syndrome  of  Little — I refer  the  reader  to  the  special 
treatises  and  monographs  : Bianchi,  ‘Treatise  upon  the  Diseases  of  the  Brain  ’ 
in  the  Patalogia  Specials  of  Maragliano  and  Cantini ; Tanzi,  ‘ Sui  rapporti 
della  cerehroplegia  infantile  colV  idiozia,’  Rivista  di  Patologia  nervosa  e 
Mentals;  Massalongo,  ' Le  diplegie  cerehrali  delV  infanzia,'  Policl.,  iSgy 
Seppilli,  La  paralisi  cerehrale  infantile,  Torino,  1898  ; Pennato  and  Berg^ 
hinz,  Le  cerehvopatie  spastiche  infantili,  1899;  and  many  others. 


456 


PSYCHIATRY 


head,  as  a rule,  is  small  and  flattened  at  the  vertex  (one  of  Tanzi’s 
cases  presented  macrocephaly) ; the  nose  is  large  and  flattened  at 
the  root,  the  point  turned  upwards  ; the  eyes  seem  very  distant 
from  one  another,  the  eyelids  thick  and  heavy  ; the  lips  are  thick, 
the  tongue  too  large,  and  projecting  from  the  mouth  ; the  milk- 
teeth  are  cast  very  early,  and  the  appearance  of  a second  set  is 
long  delayed  ; the  limbs  are  short  and  thick,  hands  and  feet  dumpy  ; 
lordosis  and  lateral  curvature  of  the  spine  are  present ; the  neck  is 
short,  the  abdomen  large  ; the  genitals  are  not  well  developed, 
true  infantilism  being  present  in  both  male  and  female  ; menstrua- 
tion is  absent  or  late.  The  skin  is  swollen,  too  ample  for  the 
body,  hard  and  resistant,  and  of  an  earthy  colour  ; the  hair  is 

scant  and  bristly  ; in  the  axilla  and 
on  the  pubis  it  is  absent  or  scant 
and  hard,  occasionally  downy.  In  the 
majority  of  cases  the  thyroid  gland  is 
absent.  In  the  posterior  part  of  the 
neck  we  frequently  find  large  deposits 
of  fat,  resembling  true  lipomata  or 
pseudo -lipomata,  and  occupying  also 
the  supraclavicular  fossae.  The  cir- 
culation is  slow,  the  temperature  low. 
There  is  great  poverty  and  torpor  of 
all  the  mental  manifestations,  as  in 
idiots  of  all  grades. 

One  of  the  patients  described  by 
Tanzi  was  at  fifteen  years  of  age  in- 
capable of  standing  erect  or  of  walking. 
She  neither  laughed  nor  wept,  neither 
called  out  nor  articulated  a single 
syllable. 

In  the  slighter  cases  of  simple  myxcedematous  imbecility,  such  as 
that  described  by  Brissaud  (very  rare),  the  intelligence  may  develop 
sufficiently,  and  the  morbid  picture  be  limited  to  all  or  nearly  all 
the  somatic  manifestations. 

This  form  may  be  found  even  more  attenuated,  giving  us  the 
myxcedematous  infantilism  described  by  many,  especially  by 
Brissaud,  Thiebierge,  Tambroni  and  Lambranzi,  and  Agostini. 
Here  we  have  to  deal  with  an  attenuated  myxoedema,  owing  to  a 
less  severe  affection  of  the  thyroid  gland,  not  truly  congenital,  but 
setting  in  during  the  development  of  the  infant.  In  the  first — > 
that  is,  in  the  classic  myxcedematous  idiot  described  by  Bourne- 
ville  (in  Italy  by  Tanzi) — there  is  present  m a noteworthy  degree 
arrest  of  skeletal,  sexual,  and  intellectual  development,  together 
with  the  characteristic  myxcedematous  syndrome,  consisting  especi- 
ally in  the  marked  cutaneous  dystrophy  with  solid  oedema.  In  the 
attenuated  form,  on  the  other  hand,  there  is  wanting  or  hardly 


Fig.  65. — Myxcedematous  Im- 
becile. 


PHRENASTHENIA 


457 


noticeable  the  solid  cutaneous  oedema  ; the  skin,  in  fact,  is  fine 
and  clear,  the  face  wrinkled  ; the  cutis  may  be  raised  in  large  folds  ; 
the  oedema,  whilst  absent  in  other  parts  of  the  body,  may  be  limited 
to  the  hands  and  feet.  The  lipomatous  nodules  are  more  or  less 
abundant  in  the  supraclavicular  regions  ; the  hair  is  fair,  the  eye- 
brows scant  ; there  is  absence  of  hair  on  the  face  and  the  pubis  ; 
the  nose  is  small,  the  cranium  irregular,  and  hypsocephalus  frequent 
(Agostini) ; the  thyroid  body  is  small ; all  the  other  psycho-somatic 
factors  are  as  in  myxoedematous  idiocy.  It  appears  that  in  some 
cases  the  solid  oedema  may  be  present  for  a time,  and  then  dis- 
appear. These  are  the  demyxoedematized  myxoedematous. 

Personal  observation,  as  well  as  the  publications  of  Ireland  and 
Thiebierge,  has  led  me  to  recognise  many  varieties  of  the  colouring 
of  the  skin  and  the  oedema  of  the  body  and  face  ; but  neither  is  it 
possible  nor  does  it  serve  any  useful  purpose  to  classify  them. 
Some  may  be  assigned  to  the  group  of  those  suffering  from  long- 
standing myxoedema,  others  cannot,  and  of  these  some  belong  to 
the  type  well  described  by  Lorain — stature  very  low,  limbs  slender, 
muscles  thin  and  hypotrophic,  abdomen  batrachian,  cranium 
more  or  less  irregular,  as  seen  in  rickets.  Some  adult  heads  present 
an  infantile  appearance  (syphilitics). 

Other  patients,  again,  belong  to  a decidedly  different  type. 
They  present  no  sign  of  myxoedema  ; they  may  show  signs  of 
giantism  or  of  dwarfism,  but  have  a white  skin,  sometimes  coloured, 
limbs  and  body  in  proportion,  nose  small  and  straight,  cranium 
regular,  no  conspicuous  stigmata  of  degeneration,  a sufficient 
intelligence.  They  are  not  at  all  repugnant,  save  for  the  fact 
that  they  have  no  hair  on  the  face  or  on  the  pubis,  and  they  have 
rudimentary  sexual  organs,  with  complete  absence  of  the  sexual 
instinct.  At  thirty  years  of  age  they  look  no  older  than  fourteen. 
I have  observed  one  of  thirty-five  years,  a chemist’s  assistant,  with 
skin  of  a rosy  white  colour,  beardless,  and  with  light-brown  hair, 
absence  of  hair  on  the  chest  and  pubis,  cranium  submicrocephalic 
but  regular,  stature  rather  high,  voice  effeminate  and  rather  shrill, 
sexual  organs  rudimentary — testicles  the  size  of  kidney  beans,  penis 
little  more  than  three  centimetres  long,  and  the  size  of  an  ordinary 
goose-quill.  Intelligence  was  developed  as  far  as  the  grade  of  the 
feeble-minded,  with  the  characteristics  of  timidity.  He  was  fond 
of  solitude  ; there  was  complete  absence  of  sexual  instinct.  It  is 
the  asexual  phrenastheniacs  who,  by  a gradation  which  we  cannot 
follow,  imperceptibly  merge  into  the  sexual  perversions  of  which 
we  shall  speak  in  another  chapter. 

Imbecility  is  often  complicated  with  the  juvenile  forms  of 
myopathy  described  by  Pilliet,  Collier,  Vizioli,  Landon  Dowen, 
Kesteven,  Mondio. 

Pathological  Anatomy. — Under  this  heading  we  have  to  dis- 
tinguish between  the  two  great  classes  — idiocy  and  imbecility. 


458 


PSYCHIATRY 


One  class  comprises  all  those  very  numerous  cases  in  which  the 
development  of  the  brain  is  incomplete,  stopping  short  at  some 
stage  in  the  evolutionary  scale,  and  in  life  its  extremes  are  repre- 
sented at  the  top  by  the  feeble-minded,  constituting  the  borderland 
with  the  sane,  and  at  the  bottom  by  extreme  degrees  of  pure  micro- 
cephaly. In  this  class  there  are  no  true  anatomo-pathological 
alterations,  but  a deficiency  in  the  number  of,  and  a defect  of 
evolution  in,  the  nerve-elements,  owing  to  an  initial  deficiency  of 
germinative  energy.  In  the  second  group  exist  lesions  either  of 
an  extensive  nature  or  distributed  in  foci,  these  occurring  at  some 
period  or  other  of  intra-uterine  life,  or  in  the  early  periods  of  extra- 
uterine  life,  and  arresting  the  development  of  the  injured  hemi- 
sphere, and  also,  in  a less  degree,  that  of  the  other  hemisphere,  so 
that  the  whole  psychic  life  is  arrested  in  its  evolution,  or  retarded 
and  injured.  In  the  first  group  epilepsy  is  rare,  in  the  second 


frequent.  In  the  former,  psychic  weakness  is  not  accompanied  by  ' 
focal  functional  disorders ; in  the  latter,  organic  residua  of  the  | 
cerebral  lesions  always  exist — spastic  hemiplegia  of  infancy,  \ 
diplegia,  hemianopsia,  deafness,  atrophy  of  the  optic  papillae,  etc.  In  i 
the  one  we  have  small  size  and  greater  simplicity  of  the  convolu-  i 
tions,  absence  or  a rudimentary  condition  of  some  of  them,  more 
frequently  of  the  third  frontal  and  of  one  or  more  of  the  com- 
municating gyri,  thus  giving  rise  to  prolongation  of  some  of  the 
fissures,  total  or  partial  absence  of  the  corpus  callosum,  etc.  ; in 
the  other  we  meet  with  foci  or  other  processes  with  manifest  con- 
sequences on  the  rest  of  the  brain,  differing  in  individual  cases 
according  as  the  malady  arises  during  the  intra-uterine  period,  or 
at  the  beginning  of  extra-uterine  life,  or  in  a brain  further  evolved. 

When  a destructive  focus  arises  in  the  cerebral  substance  of 
the  foetus,  or  perhaps  in  the  earliest  months  of  extra-uterine  life, 
the  convolutions  assume  quite  a peculiar  disposition  in  rays,  as 
observed  in  porencephaly  (Klebs,  Kundrat,  Bianchi,  Ferrier),  and 


PHRENASTHENIA 


459 


as  D’  Abundo  has  demonstrated  by  experiments  on  the  brains 
of  dogs  and  cats  (D’ Abundo,  ‘ Atrofie  cerehrali  sperimentali' 
Annali  di  Nevrologia,  1902).  In  these  cases  the  pioducts  of  the 
focal  lesions  are  absorbed,  giving  rise  to  porencephaly,  communicat- 
ing or  not,  as  the  case  may  be,  with  the  lateral  ventricles.  The 
accompanying  figures  are  taken  from  a case  of  porencephaly  in 
an  imbecile  with  infantile  spastic  hemiplegia,  but  without  epilepsy. 

In  such  cases,  when  the  lesions  affect  the  motor  zone,  the  spinal 
medulla  likewise  presents  defective  development,  or  a smallness  of 
the  anterior  cornua  and  of  the  pyramidal  columns  corresponding 
to  the  injured  hemisphere  (aplasia  or  hypoplasia). 

In  the  case  of  simple  primary  arrest  of  development,  the  giay 
substance  is  thinner,  the  nerve-cells  fewer  in  number,  less  perfect, 
and  provided  with  fewer  prolongations,  and  the  associative  paths 
less  numerous.  We  do  not  know  if  cells  in  process  of  development 


Fig.  67.— Porencephaly  : Internal  Aspect,  Lateral  Ventricle  Open. 

exist  under  the  forms  corresponding  to  the  phases  of  evolution  of 
the  nerve-cell  first  described  by  Fragnito  {Annali  di  Nevrologia, 
1902).  The  neuroglia  is  everywhere  more  than  normally  developed, 
the  neuroglial  cells  more  numerous,  the  nuclei  more  abundant. 

In  brains  belonging  to  the  second  group  the  lesions  found  are 
of  the  most  varied  nature,  and  are  regarded  as  the  residua  of  pre- 
ceding meningitis  : turbidity,  thickening  of  the  pia,  internal  and 
external  hydrocephaly,  residua  of  infective  encephalitis,  plaques 
of  sclerosis,  cysts,  or  old  softenings  of  various  extent  and  in  the 
most  varied  situations  in  one  or  both  hemispheres. 

Sometimes  the  ventricular  hydrocephaly  has  assumed  such  a 
proportion  that  the  hemispheres  have  become  a sack,  and  both  the 
white  and  gray  substance  much  attenuated  (Tamburini’s  case). 
At  the  same  time,  there  exist  the  most  diverse  alterations  in  the 
process  of  ossification  of  the  cranial  bones  : retarded  ossification 
of  the  sutures  and  formation  of  sesamoid  bones  (D’  Astros,  Lcs 
Hydrocephalies,  1898). 


460 


PSYCHIATRY 


Again,  we  may  find — and  perhaps  it  is  the  most  frequent  con- 
dition— premature  ossification  of  the  sutures,  a fact  that  has  led 
surgeons  to  believe,  contrary  to  all  good  reason,  that  craniotomy 
may  facilitate  the  development  of  the  brain,  as  if  the  latter  were 
hindered  in  its  development  by  the  inextensibility  of  the  cranial  box. 

One  of  the  most  frequent  findings  is  that  form  of  encephalitis 
described  best  in  recent  times  by  Pellizzi.  It  consists  of  a form  of 
hypertrophic  sclerosis  in  the  form  of  extensive  plaques  at  one  or 
several  parts  of  a convolution,  preferably  in  the  frontal  lobe  of 
one  or  both  sides,  resistant  to  the  touch,  of  a whitish-gray  colour, 
sometimes  projecting  above  the  level  of  the  normal  convolutions, 
composed  for  the  most  part  of  dense  bundles  of  neuroglial  fibres 

containing  rare  cells,  more  or  less 
deformed  and  altered  in  structure 
(Pellizzi,  Studii  clinici  e anatomo- 
pathologici  sulV  idiozia,  1901). 

Microcephaly,  then,  may  be 
simple  or  combined.  The  micro- 
cephalic  brains  in  pure  micro- 
cephaly, even  of  the  most  extreme 
degree,  writes  Giacomini,  always 
preserve  the  special  stamp  of  the 
type  to  which  they  belong,  and 
develop  always  in  the  same  direc- 
tion. They  contain  a smaller' 
number  of  cells,  which  are  smaller 
than  usual  and  furnished  with 
fewer  prolongations.  The  axis- 
cylinders  are  less  numerous,  of 
smaller  calibre  than  usual,  and 
less  ramified.  In  one  case  among 
many  described  by  Bourne ville  and 
Wuillamie,  the  brain,  which,  exclusive  of  the  cerebellum,  weighed/ 
only  640  grammes,  presented  no  sign  of  any  pathological  process.^ 
The  convolutions  were  simple  and  elementary.  It  was  a sort  of 
diagrammatic  brain,  such  as  is  prepared  for  demonstrations  in  the 
lecture-room. 

On  the  other  hand,  microcephaly  may  be  found  combined  with 
all  the  anatomo-pathological  processes  just  recorded.  These  either 
complicate  the  microcephaly  at  a later  stage,  inasmuch  as  the  brain 
of  the  microcephalic  individual  is  much  more  predisposed  to  the 
development  of  all  these  diverse  forms  of  inflammatory  processes 
which  we  recognise  as  belonging  to  the  pathology  of  the  brain,  or 
such  processes,  developing  for  some  time  in  a brain  which  might 
probably  have  evolved  in  a regular  manner,  hinder  its  normal 
development.  In  this  way  we  may  divide  microcephaly  into  com- 
bined microcephaly,  so  called,  and  into  consecutive  microcephaly. 


Fig.  68. — Microcephalic  Idiot  of 
Observation  I. 


PHRENASTHENIA 


461 


The  brain  in  pure  microcephaly  may  present  an  extraordinarily 
small  volume.  In  one  of  Giacomini’s  cases  it  weighed  hardly 
170  grammes,  in  another  323  grammes,  in  a third  405  grammes. 

The  microcephalic  of  Observation  I.,  whose  death  occurred 
whilst  I was  writing  this  chapter,  possessed  a brain  with  a total 
weight  of  384  grammes.  The  accompanying  photograph  shows 
the  cerebellum  projecting  behind  the  border  of  the  occipital  lobes 
and  exposed  to  view  ; it  is  also  seen  to  be  very  simple  (Fig.  69). 

The  frontal  lobes  show  the  least  development,  the  third  left 
convolution  being  totally  wanting,  whilst  the  third  right  is  scarcely 
noticeable.  The  Rolandic  zone  is  relatively  small,  the  para- 
Rolandic  lobule  is  rudimentary  ; the  first  temporal  convolution  is 
also  relatively  small.  The  visual  zone  is  better  developed  ; the 
lingual  lobule,  however,  is  almost  wanting. 


Fig.  69. — Brain  of  the  Microcephalic  Idiot  of  Observation  I. 


At  a first  examination  of  microscopic  preparations  of  the  cortex, 
the  nerve-cells  appear  much  fewer  in  number  than  in  normal 
brains,  especially  the  pyramidal  cells,  which  are  smaller  and  simpler 
(Fig.  70).  The  spinal  medulla  also  presents  marked  anomalies, 
which  would  require  a detailed  description. 

In  Donaggio’s  case,  corresponding  to  the  symptoms  met 
with  in  life,  and  resembling  a mild  form  of  the  syndrome  of 
Little,  there  was  found  at  the  post  - mortem,  in  addition  to 
general  microcephaly,  the  most  marked  hypoplasia  of  the  whole 
pyramidal  system — smallness  and  scarcity  of  the  pyramidal  cells  of 
the  Rolandic  cortex,  protoplasmic  prolongations  less  numerous  and 
less  ramified,  the  axis-cylinder  prolongations  more  attenuated  and 
less  ramified,  rarefaction  of  the  fibres  in  the  anterior  two-thirds 
of  the  posterior  segment  of  the  internal  capsule,  in  the  feet  of  the 
cerebral  peduncle,  and  in  the  crossed  pyramidal  bundle.  There 


462 


PSYCH  I A TRY 


was  a noteworthy  diminution  of  the  calibre  of  the  nerve 
fibres. 

This  fact  is  not  to  be  wondered  at,  because  in  many  cases  the 
microcephaly  is  not  uniform.  Certain  parts  only  of  the  brain 
may  be  wanting  or  rudimentary.  The  entire  prosencephalon  was 
wanting  in  the  brain  of  the  microcephalic  observed  by  Stani 
(reported  by  Giacomini).  The  corpus  callosum  and  the  olfactory 

lobe  were  absent  from  the  brain 
of  an  idiot  examined  by  Onu- 
frowicz.  Many  other  examples 
of  a like  nature  might  be  adduced. 

In  cases  of  both  pure  and 
spurious  microcephaly  one  often 
finds  micromyelia,  which  as  a 
rule  is  primary  and  concomitant 
with  the  microcephaly,  total 
(Giacomini,  Mingazini,  Donaggio) 
or  unilateral. 

, /Etiology. — All  the  causes  of 
insanity  in  general  may  be  causes 
of  phrenasthenia.  The  most 
important  and  direct  are  : mental 
weakness  of  the  genitors,  which, 
again,  may  be  a phase  of  family 
degeneration  initiated  in  some 
antecedent  generation  ; ad- 
vanced age  of  the  genitors  ; 
intermarriage  of  blood  relations 
belonging  to  psychopathic 
families ; moral  perversion  of 
the  genitors  ; syphilis  of  the 
mother  during  gestation,  or 
syphilis  acquired  during  lacta- 
tion ; the  giving  of  wine  to 
infants,  common  in  certain 
families,  especially  alcoholists ; 
and,  in  my  opinion,  also  the  use, 
very  common  in  some  provinces 
of  Italy,  of  infusions  of  poppy, 
with  the  object  of  soothing  the 
infants  during  the  day,  whilst  the  parents  are  at  work.  All 
these  are  frequent  causes  of  phrenasthenic  states.  The  same 
may  be  said  of  some  infectious  diseases  during  pregnancy, 
and  of  chronic  malarial  and  pellagrous  infection  (Ceni,  Agostini), 
and  not  infrequently  of  tuberculosis  of  the  genitors,  as  has  been 
lucidly  demonstrated  by  Maffucci  and  others,  who  have  compiled 
statistics  of  the  frequency  of  tuberculosis  among  idiots  (Piper, 


Fig.  70. — Section  through  the  Foot 
OF  THE  Second  Frontal  Convolu- 
tion. 


PHRENASTHENIA 


463 


23  per  cent.  ; Kalin,  56  per  cent.).  Injuries  of  the  foetus  during 
pregnancy  and  difficult  parturition,  with  prolonged  compression 
of  the  head  and  consecutive  lesions  (meningeal  or  even  cerebral 
haemorrhages),  and  injuries  to  the  head  after  birth,  are  perhaps 
among  the  most  frequent  causes,  apart  from  heredity,  of  the  arrest 
of  development  of  the  brain.  These  were  found  69S  times  by 
Wulff  in  1,436  phrenastheniacs,  in  9 per  cent,  by  Piper.  Amongst 
the  causes  of  insufficient  cerebral  development  there  is  also  to  be 
included  premature  parturition,  spontaneous  or  provoked,  which 
sometimes  is  accompanied  by  the  syndrome  of  Little  {vide 
Gehuchten,  Soury,  Mondio). 

Alcoholism  possesses  a strong  genetic  influence  on  idiocy.  Fere 
has  produced  at  will  monstrosities  of  embryos  by  injecting  a few 
drops  of  an  alcoholic  liquid  under  the  shell  of  an  egg  in  course  of 
incubation.  Methylic  would  be  much  more  injurious  than  ethylic 
alcohol,  and  the  latter  less  than  absinthe.  The  researches  of  Fere 
and  those  of  Martinotti,  although  partly  contradicted  by  those  of 
Mirto,  are  of  great  value.  Statistics  give  a percentage  of  idiots 
from  alcoholic  genitors  of  from  62  per  cent.  (620  in  1,000  idiots 
examined  in  Bicetre  by  Bourneville)  to  11-38  per  cent.  (Kind). 

Destructive  foci  arising  through  syphilitic  thrombosis  or  acute 
encephalitis  lead  to  the  same  result  by  a different  mechanism 
{vide  Tanzi,  Seppilli,  De  Sanctis,  and  Bianchi,  ‘ Treatise  of 
Diseases  of  the  Brain,’  in  the  Patologia  Speciale  of  Cantani  and 
Maragliano). 

Prognosis. — The  prognosis  of  well-manifested  phrenasthenia  is 
always  very  grave.  It  is  only  phrenastheniacs  of  the  highest  grade 
who  can  be  brought  into  such  a condition  as  to  prove  in  a less  degree 
a family  and  social  burden,  thanks  to  particular  curative  and  peda- 
gogic methods.  Such  phrenastheniacs,  more  or  less  disciplined  and 
corrected,  may  learn  trades  or  become  adapted  to  useful  employ- 
ments. In  the  section  for  the  mentally  deficient  at  Bicetre,  directed 
by  Bourneville,  very  many  of  them  are  employed  in  the  most 
diverse  handicrafts,  earn  a part  of  what  they  consume,  and  become 
disciplined  and  governable. 

Many  others,  consisting  of  those  of  inferior  grade,  are  not 
educable  to  the  point  of  giving  any  useful  product.  In  general, 
idiots  who  are  unable  to  speak  or  attain  possession  of  a rudimentary 
language  are  not  educable.  Those,  on  the  contrary,  in  whom 
language  is  developed,  be  it  ever  so  poor,  offer  greater  probabilities 
of  ulterior  development.  The  hereditary  phrenastheniacs  who  do 
not  fix  their  rudimentary  attention  on  anything,  and  who  manifest 
destructive  tendencies,  other  conditions  being  equal,  are  less  educable 
than  those  who  are  better  behaved  and  more  capable  of  direct- 
ing their  attention.  Microcephalies  suffer  from  more  serious  con- 
ditions than  hydrocephalics.  I have  met  with  infants  exhibiting 
marked  listlessness  and  paralysis  of  the  inferior  limbs  as  the  result 


464 


PSYCHIATRY 


of  severe  hydrocephaly,  who  with  the  lapse  of  years  have  so  de- 
veloped mentally  as  to  be  admitted  to  the  secondary  schools. 
The  slight  degrees  of  hydrocephaly  which  give  rise  in  infancy  to  a 
syndrome  of  phrenasthenia  sometimes  ameliorate  to  an  extra- 
ordinary extent  in  childhood,  and,  in  fact,  in  adolescence  the  subjects 
concerned  belie  the  characteristics  of  their  infancy,  showing  a lively 
intelligence,  sometimes  even  above  the  average.  A noted  case  is 
that  of  Helmholtz,  whose  brain  showed  at  the  autopsy  the  residue 
of  the  hydrocephaly  from  which  he  suffered  in  infancy. 

Paralysis,  blindness,  or  deafness  occurring  as  complications 
aggravate  the  prognosis. 

The  conditions  of  the  epileptic  phrenastheniacs  are  still  more 
serious.  Epilepsy  per  se  is  capable  of  arresting  the  psychic  develop- 
ment, and  of  perverting  it  at  an  early  period  in  the  social  relations. 

In  arriving  at  a prognosis  the  clinician  must  not  neglect  the 
examination  of  the  economic  and  moral  conditions  of  the  family 
of  the  phrenastheniac,  inasmuch  as  well-developed  intelligence  of 
one  of  the  parents,  the  care  that  thoughtful  and  intelligent  mothers 
take  of  their  infants,  a good  habitation  (light  and  airy),  simple  and 
well-regulated  nutrition,  are  all  factors  which,  other  things  being 
equal,  facilitate  the  psycho-cerebral  development.  As  regards 
locality,  I must  add  that  intensely  malarial  districts,  where  the 
majority  of  the  inhabitants  have  enlarged  spleen  and  a certain 
degree  of  anaemia,  are  veritable  nurseries  of  imbecility,  and  con- 
sequently do  not  offer  conditions  favourable  to  the  future  of  phrenas- 
theniacs. 

Therapy. — The  most  fertile  field  for  a rational  medical  inter- 
ference is  certainly  that  of  prophylaxis.  Since  the  majority  of  the 
causes  of  idiocy  and  phrenasthenia  are  known  to  us,  we  should 
cry  out  loudly  against  multiplication  of  cumbersome  and  useless 
beings.  Marriage,  which  is  not  an  individual  function,  but  an 
eminently  social  one,  should  be  prohibited  amongst  imbeciles, 
epileptics,  old,  mentally  decayed,  and  lascivious  men  who  marry 
young  women  attracted  by  the  mirage  of  a fine  economic  position, 
amongst  habitual  alcoholists,  uncured  syphilitics,  and  neuropathic 
blood-relations.  It  is  true  that  imbecility  sometimes  co-exists  with 
incapacity  to  fecundate,  on  account  of  profound  chemical  and  his- 
tological alterations  of  the  sperm  (own  observation),  even  when 
copulation  is  normal  ; but  it  is  also  certain  that  very  many  do 
fecundate,  and  it  would  be  well  that  the  law  and  a well-directed 
education  of  the  people  should  provide  modes  of  preventing  the 
multiplication  of  inferior  beings.  The  diminution  of  alcoholism 
and  the  prophylaxis  of  tuberculosis  and  syphilis  would  have  a 
beneficial  influence  on  the  number  of  weak-minded  individuals  in 
Italy. 

Pregnant  women  must  avoid  intense  emotions  and  physical 
traumata,  especially  on  the  abdomen.  Obstetricians  must  pre- 


PHRENASTHENIA 


465 


occupy  themselves  a little  more  with  the  application  of  the  forceps 
and  with  premature  parturition,  also  weighing  carefully  in  their 
judgment  the  remote  consequences  of  their  practices  upon  the 
cerebral  development  of  the  offspring.  This  will  be  another  means 
of  prophylaxis  of  phrenasthenia. 

Such  is  the  ideal  of  the  prophylaxis  of  mental  weakness,  but 
we  have  seen  that  the  acquired  forms  are  many.  Prophylaxis, 
then,  will  but  succeed  at  most  in  diminishing  the  number,  but 
never  in  entirely  ridding  society  of  idiots  and  feeble-minded  persons. 
For  these  is  necessary  a suitable  curative  and  educative  treatment 
in  appropriate  asylums. 

Society  must  protect  the  deficient,  and  at  the  same  time  stand 
surety  for  them.  To  provide  an  asylum  and  a school  for  these 
mal-endowed  individuals  whenever  the  family  has  not  the  means 
to  provide  for  their  subsistence,  treatment,  and  education,  is  a 
supreme  duty  of  the  State  and  of  the  public  administrators.  That 
all  phrenastheniacs  are  not  educable  is  only  too  true.  For  such, 
asylum  treatment  is  rendered  necessary  by  the  repugnance  which 
the  profound  idiot  excites  and  by  the  mockery  and  the  danger  to 
which  he  is  exposed.  The  educable  always  forms  the  subject  of  a 
long  examination  and  laborious  judgment,  because  the  task  of  the 
clinician  is,  first,  to  define  the  degree  of  development  of  the  idiot  ; 
second,  to  inquire  into  his  inclinations,  his  tendencies,  and  attitudes 
that  are  relatively  more  developed  and  capable  of  being  brought 
to  the  point  of  utilization,  and,  in  addition,  his  latent  tendencies. 
Many  deficient  persons  belonging  to  the  highest  group  of  imbeciles 
are,  as  already  mentioned,  dangerous  either  because  they  are 
eminently  susceptible  to  suggestion  or  too  obstinate  and  super- 
ficial in  their  inconsiderate  resolutions,  hence  victims  of  subterfuge 
on  the  part  of  the  astute,  and  for  them  also  the  prudent  guardian- 
ship of  the  law  is  requisite. 

Others  are  extremely  excitable  and  mobile,  lose  their  serenity 
and  directive  capacity  under  the  influence  of  trifling  oppositions,  or 
face  with  Olympic  tranquillity  dangers  which  any  normal  person 
would  avoid,  not  to  mention  the  paring  down  process  their  fortunes 
undergo  in  the  hands  of  scheming  individuals.  Others  are  pas- 
sional, litigious,  stupidly  captious,  are  aroused  by  trifles,  initiate 
ruinous  projects,  and,  as  though  overwhelmed  by  an  imperious 
monoideism,  continue  to  carry  them  out,  notwithstanding  evidence 
of  the  wrong  or  the  advisability  of  giving  in.  Thus  they  dissipate 
their  fortunes.  Others  are  excessively  talkative,  cavillers,  mischief- 
makers,  slanderers,  liars,  or  extremely  jealous  individuals ; if 
women,  egoistic,  negligent  of  their  elementary  duties,  badly  be- 
haved. In  all  these  cases  the  law  and  the  physician  should  inter- 
vene, because,  after  all,  imbecility  may  be  likened  to  a tree  passing 
through  all  the  grades  of  development,  and  branching  off  into 
moral  insanity,  paranoia,  hysteria,  and  should  be  considered  present 

30 


466 


PSYCHIATRY 


in  the  various  forms  of  criminality,  besides  all  the  grades  of  para- 
noidism. 

It  is  these  imbeciles  who  are  readily  classed  amongst  the  normal 
that  society  must  be  protected  from,  even  purified  of.  The  law  pro- 
vides for  the  less  hurtful.  Medical  science  must  furnish  more  precise 
and  certain  data  regarding  those  in  particular  whose  diagnosis  is 
more  difficult,  and  of  whose  abnormality  it  is  a more  arduous 
undertaking  to  persuade  the  legal  or  lay  magistrate,  especially 
when  there  is  the  intervention  of  experts  who  are  not  very  fas- 
tidious or  who  adapt  psychiatric  doctrines  to  diverse  interests. 

It  is  well  to  bear  in  mind,  however,  that  each  case  requires 
individual  study,  because,  since  many  imbeciles  and  weak-minded 
persons  are  useful,  and  maintain  their  position  well  in  the  social 
world,  the  doctor  and  the  magistrate  in  their  judicial  relations 
should  not  be  authorized  to  judge  them  all  alike. 

Good  nourishment,  passive  and  active  gymnastics,  massage  and 
electricity,  all  the  tonics  like  the  glycerophosphates,  iron,  cod-liver 
oil,  are  means  adapted  to  facilitate,  within  the  limits  possible,  the 
evolution  of  these  deficient  organisms.  When  idiocy  is  complicated 
by  or  dependent  upon  inflammatory  processes  in  the  cerebral 
meninges,  repeated  applications  of  vesicants  to  the  head  and 
treatment  with  iodine  will  prove  useful.  If  there  is  good  reason  to  ■ 
suspect  the  existence  of  syphilis,  recourse  will  be  had  to  mercurial  ; 
treatment.  ; 

If  complicated  with  epilepsy,  it  is  necessary  to  add  the  adminis-  • 
tration  of  proportionate  doses  of  bromides.  If  there  is  hydro-  , 
cephalus,  besides  the  aetiological  treatment  for  the  diverse  genesis  | 
and  the  various  forms  of  hydrocephalus,  mercurial  and  iodine  pre- 
parations, vesicants  to  the  head,  will  be  equally  useful,  and  we  may 
also  have  recourse  to  surgical  intervention  for  the  puncture  of  the  sac  ; 
of  the  dura  mater,  and  even  for  the  drainage  of  the  lateral  ventricle.  ■ 

The  myxoedematous  form  is  treated  by  the  internal  or  hypo-  ] 
dermic  administration  of  thyroid  juice,  or  by  tablets  of  th3Toidine,  j 
not  neglecting  all  the  other  conditions  indicated  by  the  general  i 
therapy  of  these  states.  i 

Cretinism. — This  is  an  arrest  of  psycho-somatic  development 
which  presents  itself  in  an  endemic  form  in  some  well-known  regions 
of  Europe  and  America,  but  it  is  likewise  sporadic.  It  has  somatic 
features  by  which  it  is  readily  distinguished  from  the  other  forms 
of  phrenasthenia,  and  is  of  toxic  origin. 

Symptomatology. — The  majority  of  cretins  are  born  with  the 
particular  sign  of  the  disease.  Sometimes,  according  to  some 
observers,  a small  goitre  exists  from  birth.  The  head  is  large  and 
irregular,  the  fontanelles  are  larger  than  normal,  the  forehead 
narrow,  low,  and  covered  with  hair,  often  bristly,  the  face  short, 
the  root  of  the  nose  indented,  the  nose  flat,  the  eyelids  appearing 
oedematous,  heavy,  and  not  covering  the  anterior  part  of  the  ocular 


PHREN  ASTHENIA 


467 


bulb  as  in  healthy  children.  The  face  seems  swollen,  often  of  an 
earthy  colour ; the  mouth  large,  the  lips  thick,  the  tongue  thick 
and  often  protruding  ; the  body  thick-set,  the  abdomen  large,  the 
fingers  short  and  thick,  the  spine  slightly  curved,  sometimes  the 
long  bones  of  the  lower  limbs  curved  ; the  skin  thick,  pallid,  cold, 
cyanotic,  especially  in  the  extremities,  appearing  sometimes  to 
form  a sac  too  large  for  the  contents  (Virchow). 

The  development  of  the  body  is  both  slow  and  anomalous.  The 
irregularities  in  the  head  become  more  pronounced  as  development 
proceeds.  The  ossification  of  the  sutures  is  retarded,  as  also  that 
of  the  fontanelles  ; the  goitre  is  also  more  pronounced.  Mean- 
while, on  the  functional  side,  it  is  noted  that  the  movements  are 
listless,  prehension  slow,  walking  much  delayed,  the  physiognomy 
inexpressive,  even  somnolent,  the  eyes  being  half  closed  and  the 
eyelids  listless.  The  stupidity  and  the  languor  are  unbroken  by 
any  of  those  mutations  which  in  infancy  and  childhood  express  the 
very  ready  and  rapid  motions  of  the  mind — grief,  joy,  fear,  anger, 
impatience,  etc. 

The  development  of  the  body,  besides  presenting  irregularities, 
becomes  arrested.  The  stature  of  cretins  is  much  below  the  normal. 
Their  teeth  are  anomalous  in  number  and  form  ; they  decay  early, 
fall  out,  and  are  sometimes  not  renewed.  Many  do  not  walk  before 
the  sixth  or  seventh  year ; the  upright  position  is  not  certain  before 
the  second  or  third  year.  Speech,  nearly  always  very  poor  and 
defective,  develops,  if  at  all,  more  slowly  than  walking.  Deafness 
and  blindness  (not  rare)  complete  the  picture,  from  which  the 
reader  may  form,  with  the  aid  of  the  imagination,  all  the  grada- 
tions from  the  lowest  to  the  highest,  from  both  the  somatic  and 
the  psychic  point  of  view ; and  it  is  to  be  added  that  in  cretinism  we 
can  have  all  the  modalities  known  in  idiocy  and  imbecility,  for  the 
general  symptomatology  of  both  idiocy  and  imbecility  is  perfectly 
applicable  to  cretinism.  Thus  it  is  that,  in  exceptional  cases,  we 
may  have  a cretin  who  is  adroit,  heretical,  malicious,  as  compared 
with  the  majority,  which  is  composed  of  torpid  individuals.  In  the 
same  way,  while  most  of  them  are  of  low  stature,  in  rare  cases  they 
may  show  a real  giantism,  a point  to  which  Lombroso  first  called 
attention.  These  cretin  giants  sometimes  reach  a height  of  over 
2 metres  (one  of  them  observed  by  Lombroso  measured  2-59 
metres),  and  have  a relatively  small  head. 

As  regards  the  development  of  the  senses,  we  may  refer  to 
what  has  already  been  said  of  idiots  and  imbeciles.  It  seems, 
however,  that  the  hearing  of  cretins  may  very  frequently  be  dull 
and  sometimes  absent. 

The  Sardian  Commission,  constituted  for  the  study  of  cretinism 
in  Savoy  and  the  Valley  of  Aosta,  divided  cretins,  from  the  psychic 
aspect,  into  three  categories  : (i)  The  cretins,  properly  so  called, 
those  in  whom  life  is  almost  limited  to  the  vegetative  functions  ; 

30—2 


PSYCHIATRY 


468 


1 


their  intellect  is  rudimentary ; they  have  no  speech  and  no  repro- 
ductive activity.  (2)  The  semicretins,  who  enjoy  both  the  repro- 
ductive faculty  and  a rudiment  of  language  ; the  sensory  activity 
is  more  developed,  and  they  can  satisfy  their  wants  with  a very 
limited  aptitude.  (3)  The  so-called  cretinous,  or  cretinoids,  in  whom, 
in  addition  to  some  of  the  somatic  features  described  and  the  con- 
stant presence  of  an  intellectual  deficiency,  mind  and  language, 
though  not  reaching  normal  limits,  are  yet  so  far  developed  as  to 
enable  them  to  adapt  themselves  in  very  different  ways,  and  to 
learn  various  handicrafts  more  or  less  satisfactorily,  so  that  these 
weaklings  succeed  in  securing  for  themselves  a regular  means  of 
livelihood. 

Eclampsia,  hydrocephaly,  rickets,  hernia,  are  frequent  com- 
plications of  cretinism.  _ . 

jEtiology. — We  have  already  said  that  cretinism  is  endemic 
amongst  the  heights  of  Savoy,  in  the  Valley  of  Aosta,  amongst 
the  high  Pyrenees,  in  Styria,  in  Carinthia,  Alsace,  in  some 
regions  along  the  course  of  the  Danube  and  the  Rhine,  in  the  Cau- 
casian districts,  in  some  parts  of  Derbyshire,  and  in  certain  regions 
of  Asia  and  America.  In  all  these  fairly  well  circumscribed  districts 
or  zones  cretinism  coincides  with  the  frequency  of  goitre  (a  fact 
already  demonstrated  by  Lombroso).  Goitre  is  also  frequent  m 
some  communities  of  the  province  of  Naples  which  give  a non- 
negligible  cipher  of  cretinoids.  It  appears  that  sporadic  cretinism 
is  becoming  more  rare  since  these  communities  have  enjoyed  the 
advantage  of  the  purer  water  of  the  Serine. 

It  seems  certain  that  cretinism  is  due  to  the  drinking-water. 
A few  also  are  inclined  to  think  to-day  that  the  air  contributes 
to  it.  Micro-organisms  are  not  exempted  from  the  a^tiolog}/  0 
cretinism  (Klebs,  Bircher,  Lustig,  and  Carle). 

It  is  certain  that  domestic  animals  which  drink  the  same  water 
and  breathe  the  same  air  present  goitre  and  the  phenomena  o 
cretinism.  Dogs,  horses,  and  especially  mules,  are  torpid,  stupid, 

and  goitrous.  . ^ • 

It  is  not  yet  definitely  decided  whether  the  toxins  exert  then 
influence  solely  on  the  thyroid  body,  and  through  the  latter  in- 
directly upon  the  nervous  system,  or  whether  the  action  upon  t le 
thyroid  body  and  the  brain  is  direct  and  simultaneous.  This  much 
is  certain-that  in  cretins  alterations  of  the  thyroid  body  are  con- 
stant, the  glandular  parenchyma  being  either  entirely  absent  oi 
greatly  deficient  as  the  result  of  degenerative  or  inflammatoiy 
processes  occurring  therein  (Cristiani).  The  close  relationship 
between  the  thyroid  (or  parathyroid)  body  and  the  cretinic  s\n- 
drome  is  conclusively  proven  by  a great  wealth  of  experimenta 
facts  associated  with  the  names  of  many  clinicians  and  experi- 
menters, among  whom  we  may  mention  in  particular  Munk,  Hois  ey, 
Vassale,  and  Capobianco. 


PHRENASTHENIA 


469 


The  prognosis  of  cretinism,  under  equal  conditions,  is  less  grave 
than  that  of  idiocy  (Guggenbiihl  and  others),  inasmuch  as  the 
removal  of  the  family  or  of  the  infant  who  is  commencing  to  exhibit 
signs  of  cretinism  from  the  place  where  the  disease  is  endemic  to 
a more  healthy  locality,  in  most  instances  brings  about  a remark- 
able amelioration,  and  determines  a more  regular  psycho-organic 
development.  This  is  abundantly  demonstrated  by  the  fact  that 
the  improved  hygienic  conditions  in  certain  localities  of  Switzer- 
land, France,  and  Germany  have,  during  the  last  decade  or  two, 
brought  about  a remarkable  reduction  in  the  number  of  cases  in 
those  regions. 

The  treatment  of  cretinism  can  only  be  setiological.  So  long  as 
the  conditions  determining  it  persist,  there  is  no  treatment  that 
can  be  regarded  as  truly  efficacious.  The  prophylaxis  must  not 
only  include  all  that  we  have  said  with  regard  to  the  prophylaxis 
of  the  phrenasthenias  in  general,  but  also  take  into  especial  account 
the  immediate  and  direct  causes  of  endemic  cretinism. 

There  can  be  no  doubt  that  the  wide  distribution  of  healthful 
waters  led  in  iron  conduits  into  the  small  communities  and  districts 
where  cretinism  is  prevalent,  is  to  be  regarded  as  a veritable  source 
of  health  and  strength.  In  the  Campanian  districts,  as  I have 
already  remarked,  cretinism  is  daily  diminishing  in  frequency. 
The  law  should  also  make  provision  for  the  housing  of  some  com- 
munities in  the  Valley  of  Aosta  and  the  province  of  Cuneo,  where 
the  dwellings  are  worse  than  caves,  entrance  being  effected  on  all- 
fours  through  a sort  of  hole.  Treatment  by  mountain  air,  good 
nourishment,  thyroid  and  thymus  preparations,  and  all  the  known 
tonics,  must  be  regarded  as  sufficiently  efficacious. 


CHAPTER  IV 
PARAPHRENIAS 

The  conception  of  paraphrenia  is  not  yet  clearly  defined  in  psychi- 
atry ; rather  does  there  exist  a certain  amount  of  confusion  con- 
cerning the  signification  to  be  attached  to  the  term  and  the  morbid 
forms  it  should  be  made  to  include.  Arndt,  for  example,  under- 
stands by  paraphrenia  those  forms  of  psychosis  with  psychic  en- 
feeblement  arising  after  the  period  of  childhood,  and  terms  the 
insanity  developing  about  the  time  of  puberty  paraphrenia  hebetica, 
or  hebephrenia,  and  that  occurring  at  an  advanced  age  paraphrenia 
senilis,  or  presbyophrenia.  This  distinction  leads  to  great  confusion 
in  our  conceptions  of  the  mental  affections,  the  more  so  when  we 
consider  that  the  disease  to  which  Arndt  alludes  is  paranoia  hallu- 
cinatoria,  and  that  paranoia  puberum,  paranoia  medice  cetatis,  and^ 
paranoia  climacterica,  would  all  be  paraphrenias.  s 

By  paraphrenia  I mean  that  form  of  defect  in  cerebral  evolu- 
tion manifesting  itself  in  eccentricity,  originality,  and  extravagances 
that  give  quite  a particular  stamp  to  the  character  of  the  personality, , 
which  may,  however,  exhibit  superior  intellectual  qualities,  some-, 
times  attaining  the  level  of  genius.  | 

The  character,  which  sums  up  all  the  psychic  activities  of  the- 
individual  and  betra^^s  itself  in  his  conduct,  is  the  resultant  of  the^ 
ideative  process,  the  emotions  and  the  sentiments,  as  well  as  thei 
attentive  and  volitional  power  of  the  individual,  and  the  relation 
between  the  conscious  and  unconscious  form  of  his  being.  The 
attitude  of  the  individual  considered  per  se,  and  especially  in  rela- 
tion to  his  environment,  derives  from  the  equilibrium  of  the  various 
mental  activities,  in  such  a manner  that  the  predominance  of  one 
and  the  defect  of  another  are  reflected  on  the  behaviour  and  actions, 
which  give  in  synthesis  the  individual  psychic  particularities. 

As  a rule,  the  perceptive  process  is  also  entirely  altered  in  the 
so-called  unbalanced  or  eccentric  people,  and  even  more  so  the 
process  of  apperception  of  the  effects  of  certain  acts,  which  would 
appear  to  be  withdrawn  from  the  law  of  co-ordination  of  the  life 
of  the  individual  with  that  of  the  social  environment.  All  men 

470 


PARAPHRENIAS 


471 


who  live  together,  constituting  a tribe,  a nation,  or  a race,  resort 
to  imitation  and  adaptation,  in  order  to  conform  their  customs  in 
general  lines,  in  the  most  diverse  manifestations  of  life,  to  those 
of  the  community.  Slight  and  gradual  alterations  are  introduced, 
such  as  all  those  useful  modifications,  representing  disadaptations 
and  new  adaptations,  which  sometimes  succeed  in  modifying  even 
the  instincts  (Darwin). 

In  these  successive  modifications  of  the  habits  in  adaptations 
that  tend  to  create  new  habits  more  useful  to  the  individual  and 
the  species,  lie  the  reason  and  the  mechanism  of  advancement  and 
all  future  progress.  If  men  were  incapable  of  offering  opposition 
to  the  law  of  misoneism  (Lombroso),  or  to  that  of  habit  (James),  life 
would  be  a mechanism  governed  by  the  laws  of  statics.  All  the 
expressive  or  elective  part  of  life  feels  the  irresistible  consequences 
of  the  progressive  character  of  the  perceptive  process,  which  every 
day  brings  us  more  into  contact  with  new  truths  and  new  facts, 
which  demand,  through  force  of  circumstances,  new  adaptations. 
The  developmental  or  inherited  elements  of  the  character  become  co- 
ordinated with  the  ever-changing  social  and  personal  factors  (Levy). 
By  some,  however,  the  personal  factors  would  be  regarded  as  the 
more  important  (Malapert,  Les  elements  du  caractere,  et  leurs  lots  de 
combinaison,  1897).  ■ This  explains  why  what  is  not  really  eccen- 
tricity sometimes  appears  to  be  so.  I remember  the  case  of 
J.  Han  way,  who  was  the  first  to  introduce  the  umbrella  into 
England,  and  for  this  innovation  was  pronounced  eccentric,  while 
soon  afterwards  its  utility  was  recognised  and  its  use  became 
common. 

Eccentricity  consists  at  bottom  in  an  absolute  predominance  of 
the  individual  factors,  which  originate  from  a developmental  struc- 
tural anomaly  of  the  brain,  causing  a rupture  of  harmony  between 
the  individual  and  his  environment.  The  mechanism  of  these 
anomalies  is  characterized  by  an  alteration  of  the  process  of  apper- 
ception or  of  association,  by  the  predominance  or  the  tyranny  of 
certain  emotional  or  non-emotional  ideas,  deficient  or  excessive 
emotivity,  defect  of  voluntary  attention  and  the  predominance 
of  automatism,  or  by  a marked  defect  of  regulative  power.  In  all 
these  cases  eccentricity  corresponds  to  the  individual  and  collec- 
tive futility  of  the  conduct  in  its  entirety,  or  in  one  of  its  manifesta- 
tions which,  on  the  other  hand,  clashes  strongly  with  the  prevailing 
custom,  and  accordingly  finds  no  imitators.  In  the  field  of  thought 
it  is  especially  the  strange  association  of  ideas  that  determines  the 
actions.  Caporali,  e.g.,  believed  he  was  avenging  the  supposed 
injury  done  by  Crispi  to  the  Pouille,  by  drawing  a pebble  over  his 
face. 

As  the  reader  may  judge  for  himself,  eccentricity  is  always  an 
expression  of  defect  and  want  of  harmony  in  the  cerebral  develop- 
ment, and  may  be  found  associated  with  all  grades  of  intelligence, 


472 


PSYCHIATRY 


from  imbecility  to  genius.  It  is  on  the  borderland  of  insanity,  and 
manifests  itself  in  the  most  fantastic  ways — in  the  clothing,  in  the 
personal  appearance,  in  the  hair,  in  the  style  of  writing,  in  speaking, 
in  certain  voluntary  tics,  such  as  lambdacism  and  rhotacism,  with 
the  idea  of  giving  an  affected  grace  to  the  speech.  Exaltation  of 
certain  obsessive  feelings,  such  as  exaggerated  zoo-ophily  [e.g.,  a 
lady  who  spends  a part  of  her  income  upon  and  devotes  the  greater 
part  of  her  life  to  cats  and  dogs,  maintaining  a large  number  for 
no  purpose),  the  rabid  opposition  of  some  to  vivisection,  etc.,  are 
examples  of  eccentricity.  Certain  collectors  of  useless  objects  or 
of  insignificant  animate  things,  because  of  which  such  individuals 
often  withdraw  themselves  from  the  sometimes  pressing  reality  of 
life ; some  exalted  religious  or  political  monoideists,  like  certain 
anarchists  and  the  majority  of  professed  spiritualists  ; others  who 
are  fanatical  in  their  strivings  after  a discovery  which  they  believe 
very  near  and  certain,  such  as  the  steering  of  the  balloon,  or  their 
efforts  in  poetry  and  verse,  which  they  pronounce  sublime,  assuming 
an  air  of  superiority  or  inspiration  ; the  misanthropes  (less  numerous 
now  than  formerly)  who  avoid  the  company  of  man,  and  pass  their 
time  at  home  enjoying  a pipe  and  the  good  things  of  the  table  ; 
the  sordid,  avaricious  individuals,  deficient  in  intellect  and  devoid 
of  any  sort  of  altruistic  sentiment,  who  enjoy  only  the  possession 
of  money,  and  are  torments  even  to  their  own  families — all  furnish 
numerous  examples  of  eccentricity.  To  continue  the  enumeration 
would,  I think,  be  quite  superfluous.  Anyone  can  see  that  eccen- 
tricity, in  the  sense  I have  expressed,  may  assume  the  most  diverse 
forms,  as  many,  indeed,  as  there  are  directions  of  thought,  modes 
of  feeling,  and  forms  of  action.  It  is  necessary,  however,  to  make 
some  distinctions.  Sometimes  we  meet  with  strong  personalities 
that  pay  no  heed  to  the  customs  of  others,  but  go  their  own  way. 
At  other  times  we  find  a plausible  pretext  for  the  strange  act — 
e.g.,  getting  into  a sack  of  feathers  on  account  of  cold,  and  then 
regarding  one’s  self  in  the  mirror  (Leopardi).  In  other  individuals 
there  is  absolutely  no  object  in  view,  as,  for  example,  when  they 
grow  long  hair,  and  allow  it  to  fall  over  the  face  (perversion  of  the 
aesthetic  sense,  vanity,  necessity  of  attracting  attention  to  one’s 
self,  etc.). 

Among  so  many  originals  and  eccentrics  we  find  a number  of 
imbecilic  individuals,  also  men  of  medium  ability,  and  some  most 
distinguished  persons,  such  as  Cowper,  Shelley,  Tasso,  Leopardi, 
Lord  Byron,  and  Wagner.  The  paranoic  temperament,  strong 
emotivity,  immorality,  sexual  perversions,  are  often  attributes  of 
these  bizarre,  original,  eccentric  individuals,  who  rarely  land  in 
asylums,  but  whom,  all  the  same,  the  man  in  the  street  recognises 
immediately  he  comes  in  contact  with  them. 

Some  of  them  betray  a real  want  of  equilibrium.  They  are 
dreamers,  incapable  of  appreciating  circumstances  at  their  proper 


PARAPHRENIAS 


473 


value,  or  of  finding  opportune  adaptations.  There  is  a want  of 
uniformity  or  of  co-ordination  of  the  conduct  with  the  ends  in  view, 
or  there  is  a defect  in  the  proportional  relations  between  thought 
and  action,  marked  incapacity  being  exhibited  in  the  latter.  The 
psychic  waves  rise  to  a great  height  on  some  occasions,  and  fall 
to  the  level  of  indifference  on  others. 

In  their  moods,  their  sympathies  and  antipathies — usually  irra- 
tional— as  regards  both  persons  and  things,  they  are  extremely 
variable.  There  is  no  objective  reason,  no  logic,  in  these  strange 
and  rapid  variations  of  the  mind.  Strong  desires,  followed  by 
facile  renunciation  of  the  objects  which  a short  time  before  had 
raised  their  enthusiasm,  are  also  psychological  features  of  these 
strange  beings. 

Sometimes  they  have  a vivid  imagination,  and  become  artists 
or  orators  ; but  though  well  endowed,  they  are  incapable  of  suc- 
ceeding in  anything  of  real  utility  in  their  relations  in  life.  They 
lack  the  capacity  to  weigh  the  stern  realities  of  life  ; they  are  often 
deficient  in  rectitude  and  morality,  however  much  they  may  appear 
to  possess  wide  notions  of  morals. 

Some  of  them  are  excessive  enthusiasts  in  art,  politics,  and 
religion,  or  irreconcilables  who  contradict  themselves  and  exercise 
a fierce  tyranny.  iVmong  these  I include  those  vegetarian  fanatics 
who  maintain  that  they  can  eat  those  vegetables  that  grow  under, 
and  not  those  that  flourish  above,  the  surface  of  the  earth  e.g., 
potatoes.  Many  regicides  and  political  offenders  are  known  to 
have  been  infected  with  a strong  hereditary  taint,  and  to  have 
been  ill-balanced,  eccentric,  vain,  believing  they  were  to  reform 
the  world  and  liberate  mankind  from  the  tyranny  of  sin  and  misery. 
The  truth  is,  they  were  delinquents  who  inflicted  numberless  sorrows 
on  honest,  industrious  citizens.  Such  was  Passannante  (studied  by 
Virgil),  Luccheni,  Caporali  (studied  by  me),  Ravachol,  and  many 
other  fanatics,  monoideists,  and  sanguinary  individuals  (Lombroso, 
Ferrero,  Spitzka,  Forel).  In  their  social  relations  they  exhibit 
strong  egoism,  which  is  always  a part  of  these  unbalanced  natures. 
In  business  they  end  in  ruin,  in  their  families  they  are  incapable  of 
preserving  order  or  of  training  and  educating  their  children.  They 
are  theorists,  Utopians  who,  sometimes  having  superior  intellectual 
qualities,  beguile  the  public,  who  appraise  their  intellectual  value 
from  outward  appearances  alone.  Men  of  strong  talent  are  some- 
times eccentric  as  the  result  of  distraction.  In  their  self-absorption 
they  appear  to  forget  the  most  elementary  expediencies.  A notable 
instance  is  that  of  a statesman  who  arrived  at  Court  one  evening 
wearing  a jacket,  and  it  was  only  at  the  door  that  the  attendants 
drew  his  attention  to  the  impropriety  of  that  dress  under  the  cir- 
cumstances. 

Eccentric  individuals  owe  their  natures  to  heredity.  Even 
when  originality  may  be  attributed  to  meningeal  affections  suffered 


474 


PSYCHIATRY 


in  infancy,  hereditary  predisposition  has,  as  a rule,  played  a part. 
More  rarely  does  it  take  origin  from  infective  diseases  during  preg- 
nancy, from  difficult  parturition,  injuries  to  the  head,  or  diseases 
of  infancy. 

These  natures  are  capable  of  little  modification. 

The  majority  are  but  slightly,  if  at  all,  harmful ; many,  indeed, 
are  efficacious  in  their  social  relations.  We  do  not  concern  ourselves 
with  the  therapy  of  these  states,  of  which  we  have  made  a brief 
review  with  the  sole  object  of  recognising  all  the  forms  that  defects 
of  evolution  or,  according  to  others,  degenerations  may  assume. 


CHAPTER  V 


DELINQUENCY 

As  we  have  seen  in  the  second  part  of  this  work,  the  mind  follows 
a twofold  direction  in  its  development— viz.,  knowing  and  feeling. 
By  means  of  knowledge  the  intellect  is  evolved,  by  way  of  feeling 
we  have  development  of  the  consciousness  of  the  individual  in  his 
social  relations.  The  consciousness  of  an  individual,  well  developed 
in  his  social  relations,  is  penetrated  and  pervaded  by  the  emotmns 
of  his  fellow-beings.  This  penetration  or  fusion  of  the  emotions 
of  similar  beings,  or  even  of  all  living  beings  capable  of  emotions, 
is  progressive,  but  not  always  proportionate  to  the  evolution  ^ of 
the  intellect,  and  leads  essentially  to  the  formation  of  a collective 
consciousness  in  the  individual,  and  this  at  bottom  gives  morality 
(vide  Part  IT,  Chapter  V.). 

The  less  the  evolution  of  the  collective  consciousness,  the 
more  the  individual  instincts  impress  their  own  directive  upon  the 

conduct.  • ui 

The  instinctive  nature,  wrote  Despine,  exercises  a considerably 

greater  influence  on  the  human  actions  than  does  the  intellectual 
nature.  Absence  or  defect  of  the  moral  sentiment  gives  rise  to 
action  that  is  out  of  harmony  with  the  collective  tendencies,  and 
harmful  to  others,  and  the  individual  embodying  this  state  is  an 
antisocial  being,  a source  of  danger  to  the  community  to  which  he 
belongs.  Such  a person  we  call  delinquent  or  criminal. 

We  may  verify  several  hypotheses  : 

1.  The  moral  sentiment  is  absent  or  but  slightly  developed, 
while  the  intellect  is  also  very  poor.  In  this  case  the  phenomenon 
comes  under  the  study  of  the  phrenasthenias. 

2.  The  moral  sentiment  is  absent,  and  the  intellect  so  far  de- 
veloped as  to  reach,  or  even  rise  above,  the  lower  limits  of  the  mean 
normal  individual.  In  this  case  we  have  congenital  delinquency 
and  delinquency  from  acquired  habits,  the  prototype  being  the 
born  criminal  or  delinquent. 

3.  The  moral  sentiment  is  developed,  and  contributes  to  the 
directive  of  life  under  ordinary  conditions,  but  has  feeble  powers 

475 


476 


PSYCHIATRY 


of  resistance  when  the  mind  is  crossed  by  an  emotional  current. 
Here  we  have  occasional  and  passional  delinquents. 

4.  The  moral  sentiment  is  more  or  less  developed,  but  becomes 
perverted  or  destroyed  by  a mental  disorder,  epilepsy,  or  alcoholism, 
the  mental  affection  giving  new  factors  in  the  determination  of  the 
conduct  or  action  of  the  individual  in  his  intercourse  with  others. 
Here  we  have  criminal  insanity,  or,  if  you  like,  moral  insanity. 

This  classification,  which  I have  taught  my  students  since  1886, 
is  derived  from  the  objective  examination  of  the  facts,  and,  with 
slight  variations,  is  the  same  as  that  of  the  majority  of  anthro- 
pological criminologists,  from  Ferri  to  Ingenieros  and  Kowalewski, 
who,  after  all,  have  departed  but  little  from  the  lines  traced  by 
Lombroso.  Ferri  classifies  delinquents  in  five  groups  : (i)  Born 
delinquents,  who  have  a congenital  tendency  towards  crime  -;  (2)  in- 
sane delinquents,  who  are  comprised  in  our  fourth  group  ; (3)  de- 
linquents from  acquired  habit,  the  criminality  in  this  case  being 
derived  from  their  organization  and  social  conditions  (these,  owing 
to  their  strong  resemblance  to  bom  delinquents,  should  be  classified 
with  them  in  a single  group,  which  is  second  in  my  classification)  ; 
(4)  occasional  delinquents  ; (5)  passional  delinquents.  There  is  no 
reason  why  these  last  two  groups  should  be  separately  classified. 
The  individuals  composing  them  are  all  emotional,  impulsive, 
neurasthenic,  or  intoxicated  with  alcohol  {vide  Lombroso,  the 
various  editions  of  his  Homo  Delinquente ; Ferri,  Studii  sulla 
Criminalitd  ed  altri  saggi,  1901  ; the  Proceedings  of  the  Congres 
d’’ Anthropologic  criminelle  de  Geneve).  In  a recent  lucid  as  well 
as  comprehensive  publication  on  this  subject  {Dos  paginas  de 
Psiquiatria  criminal,  Buenos  Ayres,  1900),  Ingenieros  classifies 
delinquents  in  three  groups  : 

1.  Individuals  given  to  crime  through  an  anomaly  in  the  moral 
sphere,  congenital  (born  delinquents  or  morally  insane)  or  acquired 
(delinquents  from  habit). 

2.  Individuals  given  to  crime  through  an  anomaly  in  the  intel- 
lectual sphere,  congenital  (delinquents  through  congenital  insanity) 
or  acquired  (delinquents  through  toxic  insanity,  political  obsession, 
etc.). 

3.  Individuals  prone  to  crime  through  an  anomaly  in  the  voli- 
tional sphere,  congenital  (congenital  impulsive  delinquents)  or 
acquired  (occasional  delinquents). 

To  these  groups  Penta  would  like  to  add  a fourth,  that  of  the 
primitives.  Such  would  be  the  ancient  types  that  have  undergone 
no  miodification,  and  repeat  themselves  in  the  country  from  genera- 
tion to  generation,  with  the  same  anthropological  and  psychological 
characteristics  as  the  aboriginal  savages.  These  come  under  our 
second  group,  which  I hold  to  include  many  individuals  with  primi- 
tive characteristics.  The  primitive  nature  is  met  with  throughout 
the  same  social  class  as  furnishes  the  majority  of  born  delinquents. 


DELINQUENCY 


477 


In  the  latter  we  find,  in  many  regions,  a true  delay  in  evolution 
(vide  Bianchi  and  Lombroso,  Misdea,  Naples,  1884). 

More  or  less  commendable  reasons  might  be  adduced  in  favour 
of  one  or  other  of  the  classifications,  but  it  is  undesirable  to  discuss 
them  here.  I would  only  note  that  defect  of  the  moral  sentiment 
in  the  delinquents  of  the  second  group  in  my  classification  may 
have  a double  origin,  thus  giving  rise  to  a natural  division  into  two 
subgroups.  In  one  the  evolutionary  defect  is  developmental,  depend- 
ing on  anomalous  cerebral  structure  through  weakness,  degenera- 
tion, mental  disorder,  or  alcoholism  in  the  parents.  This  subgroup 
is  composed  of  born  criminals,  properly  so  called.  In  the  other 
subgroup  heredity  plays  no  part,  or  at  least  not  a prominent  one. 
The  evolutive  potentiality  of  the  social  animal  is  present,  but  from 
infancy  • favourable  individual  and  environmental  conditions  and 
circumstances  are  absent  ; mal-nutrition,  disease,  prostitution  and 
alcoholism  of  the  parents,  bad  example,  evil  company,  etc.,  are 
present,  to  the  exclusion  of  the  conditions  requisite  for  a regular 
mental  development.  This  group  comprises  the  so-called  delin- 
quents from  acquired  habit. 

The  psychology  of  the  former  differs  in  no  way  from  that  of 
the  latter.  Anthropological  degenerative  signs  are  more  frequent 
in  born  criminals  than  in  criminals  from  acquired  habit,  who  are 
also  capable  of  greater  modification  ; but,  in  all  its  manifestations, 
the  life  of  the  one  resembles  that  of  the  other  group  in  every  point. 

In  this  chapter  we  need  not  occupy  ourselves  with  either  the 
first  or  the  fourth  group.  We  have  already  alluded  to  the  crimi- 
nalit}^  of  phrenastheniacs  when  treating  of  such. 

We  are  already  acquainted  with  the  mechanism  and  dynamism 
of  criminality  in  imbeciles.  Given  the  absolute  dominion  of  the 
egoistic  sentiments  in  imbeciles,  their  criminality  depends  upon 
the  intensity  of  their  desires  and  on  the  degree  of  development  of 
their  instincts  and  emotions.  Since  there  exist  phrenastheniacs 
with  the  sexual  instinct  absent  or  feeble,  we  will  not  expect  of  them 
offences  against  chastity,  just  as  timid  or  fearful  imbeciles  will 
not  be  the  protagonists  in  bloody  crimes,  even  when  they  have 
thoughts  of  avenging  themselves  for  some  injury,  real  or  imaginary. 
There  is  the  irascible  and  impatient  imbecile ; there  is  the  feline, 
the  indolent,  and  the  cowardly  imbecile ; the  imbecile  who  indulges 
in  shocking  dissipation,  and  the  imbecile  sordidly  avaricious  ; there 
is  the  lazy  vagabond,  the  thief,  and  the  aggressive  character.  Now, 
it  is  evident  that,  given  great  differences  in  the  minds  of  phrenas- 
theniacs, the  latter  may  or  may  not  be  delinquents.  Their  crimes 
will  have  quite  a different  origin,  and  the  mechanism  will  be  different 
in  different  cases,  though  always  bearing  the  stamp  of  mental 
weakness,  as  we  have  already  seen. 

The  imbecility  reveals  itself  in  the  means  and  methods  they 
employ  to  attain  their  ends,  and  in  their  utter  want  of  foresight, 


478 


PSYCHIATRY 


showing  clearly  a great  lack  of  appreciation  (imagination,  memory) 
of  the  more  or  less  remote  consequences  of  a given  action.  One 
noteworthy  example,  among  many,  is  that  reported  by  Sanna 
Salaris  : 

The  case  is  that  of  a young  man,  of  twenty-two  years,  who  had  stolen 
seven  gold  rings,  which  he  took  from  the  fingers  of  the  statue  of  the 
Madonna  in  the  parish  church.  When  arrested,  he  confessed  his  crime, 
but  excused  himself  by  accusing  another  person  as  being  the  instigator 
of  the  deed.  It  was  clearly  proved,  however,  that  the  latter  had  had  no 
relation  whatever  with  the  culprit.  This  same  young  imbecile  arrived 
home  one  day,  riding  at  a great  speed  a horse  that  had  been  entrusted  to 
his  care  by  a stranger.  On  another  occasion  he  stole  a watch  from  a 
magistrate,  and  gave  it  to  his  own  mother,  telling  her  he  received  it  as  a 
gift  from  the  magistrate’s  wife,  and  asking  her  to  buy  him  a horse  with  it. 
Another  time  he  stole  a watch  and  chain  from  the  brigadier  of  the  Custom- 
House  Guards,  and  then  paraded  the  streets  showing  off  the  chain,  which 
was  hanging  from  his  vest.  Great  deficiency  of  attention  and  foresight 
is  very  evident  in  all  the  crimes  he  committed,  although  a certain 
degree  of  improvidence  is  discernible  in  all  criminals. 


The  delinquent  of  the  second  group  presents  notable  physical, 
physiological,  and  psychic  features.  To  Lombroso  and  his  school, 
as  well  as  to  the  majority  of  Italian  psychiatrists,  belong  the 
credit  of  having  methodically  studied,  collected,  and  classified 
these,  so  that  few  now  have  any  doubt  of  their  semeiological  value 
as  an  expression  of  defective  and  anomalous  evolution  of  the  central 
nervous  system,  reflecting  itself  especially  in  the  conduct. 

Here  certain  brief  considerations  may  be  mentioned  with  advan- 
tage. We  know  that  the  same  anomalies  are  met  with,  as  we  saw 
at  the  outset,  in  the  delinquents  of  the  first  and  fourth  groups, 
and  we  can  add  that  they  may  be  found,  without  any  special  psycho- 
logical significance,  in  all  the  beings  classified  in  this  first  great 
group  wherein  we  have  brought  together  all  the  defects  of  mental 
evolution. 

It  is  well,  however,  to  come  to  an  understanding  upon,  and  to 
express  in  the  dearest  possible  manner  our  real  notion  of,  this 
question.  Observation  has  shown  that  many  delinquents  do  not 
present  the  anthropological  anomalies  that  characterize  the  majority 
of  them  ; on  the  other  hand,  many  men  who  do  present  those 
anthropological  features  are  not  delinquents.  We  can  agree  with 
what  has  been  confirmed  repeatedly  since  Sergi  had  occasion  to 
express  his  ideas  on  the  matter,  ideas  confirmed  by  the  observa- 
tions, first  of  Benedikt  and  then  of  others — viz.,  that  the  anomalies 
which  do  not  reveal  themselves  in  the  conformation  of  the  body 
may  be  found  in  the  cerebral  mantle  (convolutions  and  sulci)  ; 
on  the  other  hand,  it  may  be  asserted  that  those  who  present 
degenerative  anthropological  signs,  even  when  not  actual  delin- 
quents, possess  the  delinquent  mind  in  a state  of  latency.  This 
hypothesis  is  related  to  another — viz.,  that  where  neither  degenera- 


DELINQUENCY 


479 


tive  anthropological  signs  nor  apparent  anomalies  in  the  conforma- 
tion of  the  brain  are  to  be  found  anomalies  may  exist  in  its  intimate 
structure.  Indeed,  it  is  in  these  last  anomalies  that  we  must 
recognise  the  true  anatomical  substratum  of  the  anomalous  con- 
duct. There  is  the  other  fact,  however,  that  in  many  cases  pre- 
senting features  of  anthropological  degeneration  there  is  no  cor- 
responding form  of  delinquency.  As  regards  latency  of  criminality, 
I believe  it  exists  in  the  majority  of  men  in  the  period  of  youth. 
The  egoistic  and  antisocial  tendencies  remain  atrophic  as  compared 
with  the  enormous  development  of  the  sentiments  of  human  soli- 
darity among  evolved  and  educated  men,  and  an  attempt  to  trace 
the  dividing -line  where  physiological  latency  ends  and  morbid 
latency  begins  presents  insurmountable  difficulties.  In  this  matter 
there  is  never  complete  agreement  amongst  even  the  most  convinced 
upholders  of  the  anthropological  type  of  the  delinquent. 

There  are  two  factors  in  the  conduct — heredity  and  environ- 
ment in  the  widest  sense.  Psychopathic  heredity  in  most  instances 
betrays  itself,  under  the  most  varied  forms  and  in  the  most  diverse 
directions  of  the  mental  activity,  in  dissolution  (here  I am  pleased 
to  make  use  of  an  old  term  introduced  into  our  nomenclature  by 
H.  Jackson),  which  signifies  a breaking  up  of  the  mental  organism, 
considered  in  the  historical  moment,  with  loss  of  the  most  recent 
products  of  evolution — regulative  capacities  in  the  fields  of  thought 
and  sentiment — resulting  in  immorality  and  simpler  reflexes  tra- 
versing smaller  circuits,  and  a proportionate  overpowerful  impulsive- 
ness of  the  individual  in  his  interhuman  relations. 

The  environment  exercises,  by  the  law  of  imitation,  a continual 
suggestivity  on  the  mental  constitution  of  children  and  young 
men.  In  the  creation  of  ideas  by  means  of  example,  in  the  arousing 
of  desires  and  tendencies,  the  determination  of  impulses,  in  the 
opening  of  new  currents  of  emotions,  collective  and  beneficent — 
in  all  these  lies  the  potency  of  the  environment.  Now,  if  we  possess 
the  proof  that  the  anthropologically  degenerate  types,  placed  or 
reared  in  normal  educative  surroundings,  exhibit  weaker  and  more 
governable  criminal  tendencies,  we  must  conclude  that  anthropo- 
logical degeneration  and  delinquency  are  not  two  synonymous 
terms,  but  are  two  concomitant  associated  facts  which  may  remain 
isolated  and  distinct  from  one  another. 

I certainly  cannot  wholly  agree  with  Colajanni,  who,  in  his 
magnificent  work  {La  Sociologia  Criminate,  1887)  maintained  with 
a great  wealth  of  arguments  that  delinquency  was  a special  product 
of  unfavourable  circumstances,  especially  of  misery.  Psycho- 
pathic heredity  has  an  influence  quite  as  harmful  and  certainly 
more  fatal,  but  I do  not  feel  warranted  by  the  facts  in  renouncing 
my  strong  conviction  concerning  the  possible  diminution  of  the 
tendency  to  crime,  even  when  the  psycho-anthropological  structure 
from  which  we  infer  its  existence  be  such  as  to  leave  no  doubt  as 


480 


PSYCHIATRY 


regards  the  high  degree  of  moral  insufficiency.  I hold  that  the 
man  who  is  a candidate  for  delinquency  is  capable  of  modification 
when  placed  for  a time  under  conditions  favourable  to  moral  de- 
velopment. The  assertions  to  the  contrary  have  arisen  from  the 
fact  that  scarcely  any  State  possesses  institutions  perfected  and 
designed  for  the  education  of  this  particular  group  of  deficients. 
The  reformatories  and  the  houses  of  correction  are,  with  a few 
happy  exceptions,  schools  of  delinquency  more  than  anything  else. 
Unmodified  and  unmodifiable  types  of  delinquents  do  not  exist, 
in  an  absolute  sense,  except  in  so  far  as  the  environment  in  which 
the  candidate  for  criminality  lives  and  develops  remains  unaltered. 
There  are  few  exceptions  to  this  law,  and  these,  if  closely  examined, 
will  be  found  to  belong  to  criminality  of  the  fourth  group ; they 
comprise  cases  of  true  epileptics  or  paranoiacs,  with  whom  the  born 
criminal  has  many  points  in  common  and  many  analogous  features 
(Lombroso),  but  these  must  not  be  confounded. 

The  fact  that,  in  the  highest  classes  of  society,  degeneration 
manifests  itself  in  another  form,  is  another  proof  in  support  of  our 
argument.  Among  the  wealthy  the  primitive  form  of  delinquency 
is  much  rarer  : theft,  homicide,  rebellion  against  the  public  authority, 
are  much  less  frequent  ; the  degeneration  betrays  itself  in  conduct 
harmful  to  the  individual  himself— in  the  squandering  of  his  own 
means,  in  idleness  and  vagabondage,  in  games  of  chance  and  sexual 
orgies,  sometimes  in  alcoholism,  and,  at  the  very  worst,  in  swindling  ; 
as  a rule,  they  refrain  from  theft  and  the  shedding  of  blood. 

There  is  no  such  thing,  then,  as  an  anthropological  type  of 
delinquent  ; in  other  words,  given  an  anomalous  anthropological 
structure,  with  those  signs  happily  defined  by  Lombroso  and  after- 
wards by  other  Italians  and  foreigners,  it  does  not  always  follow 
that  actual  delinquency,  much  less  a determinate  form  of  it,  is 
associated  therewith.  All  the  inquiries  into,  and  statistics  dealing 
with,  this  matter  (and  these  are  now  fairly  abundant)  permit  the 
conclusion  that  the  so-called  anthropological,  and  perhaps  also  the 
functional  anomalies,  are  more  frequently  met  with  in  delinquents 
than  in  normal  individuals — that  is  to  say,  they  give  the  hypo- 
thetical presumption  of  a latent  disposition  tow^ards  criminalit}^ 
The  very  fact,  however,  that  the  same  anthropological  features  are 
met  with  in  a conspicuous  number  of  persons  living  in  perfect 
harmony  with  the  social  laws  in  the  common  environment, deprives 
them  of  the  character  of  specificity.  Favourable  social  conditions, 
along  with  a period  of  rational  education  and  comfortable  circum- 
stances, favour  the  development  of  the  moral  sense  to  a degree 
sufficient  to  enable  the  individual  to  adapt  himself  to  his  surround- 
ings. This  proposition  is  amply  demonstrated  by  the  fact  that  the 
conduct  of  those  degenerates  who  have  been  educated  in  well-con- 
ducted houses  of  correction,  although  suffering  from  grave  heredi- 
tary blemishes,  is  often  beyond  reproach. 


DELINQUENCy 


481 


Children  and  youths,  almost  all  candidates  for  delinquency, 
entrusted  to  the  maternal  house  of  the  Ravaschieri  in  Naples  ; those 
educated  in  the  as3dum  connected  with  the  Sanctuary  of  Pompeii, 
all  children  of  delinquents  ; and  those  referred  to  in  the  report  of 
Dr.  Lojacono  * on  the  young  misdemeanants  examined  in  the 
hospice  of  S.  IMartino  in  Palermo  (Proceedings  of  the  Congress  of 
Italian  Phreniatrists  in  Ancona),  amply  demonstrate  to  what 
extent  education  is  able  to  alter  the  mental  dispositions,  in  spite 
of  the  degenerative  forms,  which,  as  everyone  understands,  undergo 
no  modification. 

Delinquency,  then,  is  not  inevitably  and  indissolubly  bound 
up  with  the  degenerative  forms  ; its  development  is  undoubted!}^ 
favoured  by  certain  social  conditions  which  supply  the  most  stimu- 
lating food-material  for  the  more  or  less  active  growth  of  the  trans- 
mitted seeds  of  delinquency. 

From  a psychological  point  of  view,  immorality  and  delinquency 
have  always  the  same  value,  no  matter  what  the  vestments  they 
assume  in  the  manifold  directions  in  which  the  social  life  manifests 
itself. 

In  a chapter  on  delinquency  I cannot  refrain  from  touching 
upon  one  form  of  it  that  is  altogether  modern. 

There  is  the  brigand,  the  city  thief,  the  merchant  who,  trading 
on  the  good  faith  of  others,  cleverly  prepares  a bankruptcy  ; there 
is  the  bandit  who  asks  a proprietor  to  pay  a ransom,  holding  hostage 
a member  of  his  family,  a herd  of  cattle,  or  the  crops  in  the  fields, 
which  he  might  destro}^  with  fire  ; there  is  the  blackmailer  who, 
having  obtained  possession  of  a family  secret,  extorts  sums  of 
money,  holding  in  hostage  the  good  name  of  the  family  ; there  is 
the  usurer  who  speculates  upon  poverty,  and  the  functionar} 
who,  exercising  favouritism,  hides  his  fault  under  a cloak  of  irre- 
sponsibility^ ; there  is  the  public  official  who  embezzles  the  funds 
entrusted  to  him,  and  the  executor  who,  through  favouritism  and 
for  personal  ends,  spoils  the  future  of  a more  meritorious  candidate. 
Every  man  who  fills  a public  office,  but  fails  to  fulfil  his  duty,  or 
who  abuses,  for  selfish  ends,  the  privileges  he  enjoys,  to  the  more  or 
less  grave  injury  of  others,  is  immoral  and  delinquent.  We  have 
been  accustomed  to  consider  only  the  primitive  form  of  delinquency 
in  its  relations  with  criminal  anthropology,  but  the  field  of 
inquiry  must  be  widened.  This  second  form  of  delinquency,  in 
its  social  and  psychological  relations,  is  as  important  as  the 

* Atti  del  Congresso  dei  freniatri  italiani  in  Ancona.  This  report  deals 
with  400  children,  many  of  them  the  children  of  insane  parents  and  of  the 
worst  Sicilian  criminals,  whose  psychic  development  Dr.  Lojacono,  by  my 
advice,  has  been  able  to  follow  since  1889,  having  succeeded  in  keeping  them 
in  sight,  under  the  most  diverse  circumstances,  after  their  discharge  from  the 
training-school,  which  in  its  organization  is  one  of  the  best  in  Italy.  All 
of  them  were  trained  to  work  ; they  all  derived  an  honest  living  amidst  the 
difficulties  of  the  environment. 


31 


482 


PSYCHIATRY 


other.  What  has  the  anthropological  criminologist  said  with 
regard  to  it  ? 

If  the  smallest  thing  is  said,  written,  or  done  reflecting  upon  the 
honour  of  a conscientious  individual  who  is  exceedingly  jealous  of 
his  honourable  reputation,  the  injury  he  suffers  is  much  greater 
than  that  experienced  by  another  individual  wounded  by  the  knife 
of  an  assailant ; the  bestowal  of  a post  which  has  been  denied  a 
more  meritorious  candidate  does  much  greater  harm  than  an  act 
of  theft  or  plunder.  Whilst  society  and  the  law  severely  punish  the 
assailant  and  the  thief,  they  deal  much  more  leniently  with  the 
crafty,  astute  slanderer  and  with  the  distributor  of  favours,  if, 
indeed,  they  do  not  increase  his  importance. 

The  truth  is  that  immorality  is  much  more  extensive,  and  tends 
to  extend  its  dominions  in  proportion  as  the  sphere  of  human 
activities  and  the  social  relations  of  the  individuals  become  larger  ; 
delinquency  is  tending  to  transform  itself  from  the  primitive  to  a 
polished  form  : we  might  say  that  it  is  becoming  modernized. 
With  regard,  however,  to  this  modernized  form,  we  do  not  yet  possess 
anthropological  and  psychological  studies,  nor  sufficient  laws. 
Nevertheless,  the  problem  is  to  be  regarded  under  the  purely 
psychological  and  psychopathological  aspect.  All  we  have  said, 
then,  of  delinquency  refers  to  the  primitive  form  of  it,  which  differs 
from  the  other  in  the  simplicity  of  means  and  methods,  as  well  as 
in  the  frequent  impulsiveness  and  ferocity.  Such  delinquency  as 
this  closely  resembles  that  of  savages  and  primitive  peoples.  The 
egoism  of  modernized  delinquency  is  better  served  by  the  intellect 
of  the  actor  and  the  ignorance  of  the  sufferer  ; its  modern  vestments 
render  it  less  evident  and  less  demonstrable  ; the  danger  it  produces 
is,  to  all  appearance,  less  appreciable  ; its  gloves  and  dress-coat 
secure  it  a pleasant  reception  even  in  elegant  drawing-rooms  and 
in  public  ofhces. 

We  may,  notwithstanding,  suppose  that  this  more  modern  form 
of  delinquency  is  also  a sign  of  defective  cerebral  evolution,  and 
up  to  a certain  point  it  is  favoured  by  a defective  education  and 
by  the  ever-increasing  difficulties  and  hardships  of  life. 

It  is  certainly  one  proof  of  weakness,  for  it  allows  to  human 
action  smaller  circuits  and  less  resistance,  as  compared  with  the 
resistance  the  environment  opposes  to  efficacious  labour.  Here, 
however,  we  cannot  discuss  in  detail  this  form  of  delinquency,  for 
it  takes  us  outside  the  actual  limits  of  psychiatry  and  into  the  full 
domain  of  sociology.  Having  indicated  these  new  extensions  that 
are  offered  to  criminal  anthropology,  we  may  at  once  declare  that 
it  is  our  intention  to  occupy  ourselves  only  with  the  primitive  form 
of  delinquency,  which  permits  a clearer  perception  of  physical  as 
well  as  functional  and  psychic  signs  arising  through  defective  and 
anomalous  cerebral  development.  These  signs  are  met  with  in 
varying  proportions  in  all  the  four  groups,  but  to  a greater  extent 


DELINQUENCY 


483 


in  the  first,  second,  and  fourth  than  in  the  third,  as  may  readily 
be  understood.  Of  the  first  group  we  have  already  spoken  in  the 
preceding  chapter  on  the  phrenasthenias  ; of  the  fourth  and  the 
third  we  shall  speak  subsequently  in  the  chapters  dealing  with 
hysteria,  epilepsy,  paranoia,  neurasthenia,  etc.  Here  we  shall 
limit  ourselves  to  a brief  review  of  the  second. 

Symptomatology  of  the  Criminal,  including  the  Born  Criminal 
and  Criminal  from  Acquired  Hahit. — Three  groups  of  symptoms 
are  to  be  distinguished — the  morphological,  the  functional,  and  the 
psychological. 

The  anthropological  signs  in  the  criminal  are  the  same  as  those 
I have  already  mentioned  in  the  first  chapter  of  this  part — the 
predominance  of  the  face  over  the  cranium  with  respect  to  the 
physiological  type,  the  large  size  of  the  jaws,  the  bulkiness  of  the 
muscles  of  mastication,  the  structure  of  the  forehead  (in  most 
instances  narrow,  low,  and  receding),  plagiocephaly  and  plagiopro- 
sopia,  orbital  apophyses  large  and  projecting,  the  occiput  flat, 
the  canine  teeth  very  long,  etc.,  are  those  most  frequently  met  with. 
Black  hair  (Lombroso,  Marro,  Thomson)  more  commonly  than 
fair,  greater  simplicity  of  the  palmar  furrows  (Carrara),  asymmetry 
of  the  upper  limbs,  formation  of  a membrane  between  the  toes 
resembling  the  membrane  of  some  web-footed  animals,  macro- 
dactylism,  polydactylism,  prehensile  foot  (Penta,  ' Di  alcune  piu 
importanti  anomalie  e del  loro  significato  reversivo  nelle  mani  e nei 
piedi  dei  d.elinquentif  Annali  di  Nevrologia,  1894),  median  occipital 
depression  (Lombroso),  anomalies  of  the  sulci  and  convolutions 
(Benedikt,  Raggi,  and  others),  are  the  principal  facts  reflecting 
the  anomalies  of  form  which  congenital  delinquency  bears  in  common 
with  epilepsy,  imbecility,  and  the  other  grave  forms  of  degeneration, 
and  in  common  also  with  the  other  forms  of  that  inferior  life  which 
assumes  a degeneration  that  is  not  criminal.  It  is  evident,  then, 
that  while  in  the  anthropological  type  of  delinquent  there  are  wanting 
specific  characteristics,  notes  of  recognition,  there  certainly  exists 
a degenerative  type,  the  anthropological  signs  of  which  coincide 
fairly  frequently  with  delinquency,  yet  are  not  specific  of  it. 

Let  us  now  see  what  are  the  functional  anomalies  that  Lombroso 
and  some  of  his  pupils  have  met  with  in  the  born  delinquents. 

The  expression  of  the  physiognomy  is  more  readily  perceived 
by  intuition  than  by  examination  in  detail.  Rather  small  stature, 
low  and  receding  forehead,  black  and  woolly  hair,  oblique  eyes 
with  sinister  and  cynical  look,  often  deeply  set  under  protruding 
and  large  supraciliary  arches,  lop  ears,  flat  or  deviated  nose,  long 
and  large  face,  thin  lips,  large  jaw-bones,  pale  and  sometimes  beard- 
less face,  are  the  principal  features  of  the  physiognomy  of  the  born 
criminal,  and  also  of  the  criminal  from  habit. 

Even  functional  anomalies  are  common  to  degenerates  in  general 

31—2 


4§4 


PSYCHIATRY 


and  to  the  primitive  persons  we  find  here  and  there  in  our  provinces. 
The  diminution  of  tactile  fineness,  as  is  apparent  in  comparison  with 
the  polished  man  of  the  city,  is  the  same  as  we  meet  with  in  our 
peasants,  who,  illiterate,  uncultured,  but  sufficiently  intelligent, 
have  never  been  far  from  the  village  or  the  ground  they  cultivate. 
Be  they  primitive  or  degenerate,  the  majority  of  delinquents 
exhibit  a defect  of  sensibility.  Lombroso,  Ottolenghi,  Roncoroni, 
and  Angiolella  are  agreed  on  this  point,  and  bring  forward  in 
support  of  it  many  personal  observations  on  the  delinquents  con- 
fined in  the  Sales  asylum.  A like  defect  in  painful  sensibility  is 
present.  Criminals  are  almost  all  hypoalgesic. 

That  hypoalgesia  may  be  the  basis  of  cruelty,  as  Lombroso  has 
maintained,  is  more  than  probable  ; many,  however,  have  observed 
in  criminals  a great  dread  of  pain,  which  they  bear  badly  (Jolly, 
Naecke,  Baer,  Der  V erhrecher  in  antroj)ologischev  Beziehung,  1893). 
The  fact  remains,  however,  that,  be  it  from  boldness  or  otherwise, 
many  delinquents  do  not  utter  a single  groan  during  painful  opera- 
tions ; some  mutilate  themselves  ; many  tattoo  themselves,  and 
this  is  known  to  be  a painful  procedure.  Kowalewski  tells  of 
criminals  who  received  a most  extraordinary  number  of  lashes  with 
the  whip,  and  yet  bore  this  very  savage  punishment  without  emitting 
a cry.  They  restrain  from  moaning,  even  to  the  point  of  fainting. 
The  absence  of  vocal  expressions  of  pain  is  no  sure  sign  of  hypoal- 
gesia ; proof  of  it,  however,  is  found  in  the  algometric  researches 
with  the  sledge  of  Dubois-Raymond  or  other  algometers  (Roncoroni). 

Deep  muscular  sensibility  is  normal.  Criminals  show  pre- 
cision in  delicate  movements,  as  in  picking  pockets,  or  in  attack- 
ing a victim  with  a razor,  cutting  his  face,  as  a rule,  in  the  middle 
part  of  the  cheek. 

Sight  is  keen,  though  Daltonism  is  frequent,  and  the  visual  field 
often  restricted,  as  in  epilepsy  and  hysteria  (Ottolenghi  and  others). 
Smell  is  highly  developed  in  some  cases,  but  for  certain  odours 
onl}'"  ; it  often  happens  that  they  do  not  recognise  or  differentiate 
the  delicate  odours  of  the  aromatic  series.  Defects  and  anomalies 
of  the  sense  of  taste  are  also  frequent  as  regards  both  fundamental 
and  aromatic  tastes.  The  muscular  force,  when  voluntarily  directed, 
as  in  the  examination  with  the  dynamometer,  is  relatively  poor. 
In  some  cases,  however,  it  is  much  above  the  average.  One  of 
the  delinquents  confined  in  the  Sales  asylum  used  to  lift  two  hundred- 
weights with  marvellous  ease  (he  was  a Customs  House  porter)  ; 
another,  for  many  months  in  Sales,  had  killed  a man  by  a blow 
with  his  fist  ; he  possessed  herculean  strength.  The  adroitness  and 
instantaneousness  of  movement  of  these  subjects  under  the  influence 
of  emotional  states  and  their  torpor  and  slowness  under  ordinary 
conditions  are  remarkable  (passionate  emotivity,  or  emotivity 
associated  with  personal  interests).  It  is  no  rare  thing  to  meet  with 
left-handedness  or  with  ambidexterity  (Lombroso),  due  partly 


DELINQUENCY 


485 


to  an  evolutionary  and  educational  defect  (as  amongst  rural  people 
who  have  not  learned  to  write),  and  partly,  in  my  opinion,  to  diseases 
of  infancy,  (trauma,  meningitis,  meningeal  thickening  from  intoxica- 
tion, with  predominance  of  action  on  one  hemisphere).  In  some 
cases,  in  reconstructing  the  history,  we  make  out  the  existence 
of  convulsions  (eclampsia)  during  infancy,  most  frequently  on  the 
right  side.  This  fact  may  explain  the  functional  defect  of  the 
musculature  on  the  right  side  (retarded  evolution  of  the  left  hemi- 
sphere). 

Psychology  of  the  Delinquent. — The  anomalous  mental  develop- 
ment of  this  class  of  antisocial  men  manifests  itself  from  childhood 
Restlessness,  violent  reaction  against  members  of  the  family  and 
against  companions,  a certain  threatening  attitude  when  they  are 
unable  to  attain  an  end  or  are  prevented  from  satisfying  their 
proper  wishes,  want  of  reason  and  lack  of  moderation  in  their  desires, 
the  pretexts  they  bring  forward  in  opposition  to  ail  good  advice 
and  the  authority  of  their  parents,  quick  temper  and  irascibility — 
these  are  all  frequent  facts.  Intolerance  of  the  checks  put  upon  them 
and  of  the  discipline  observed  in  their  families,  thus  leading  them 
often  to  run  away  from  home  and  give  themselves  up  to  vaga- 
bondage ; the  mean  tricks  they  play  on  their  teachers,  their  rela- 
tives, and  friends  ; obstinacy,  petulance  growing  by  degrees  into 
violence  ; cruelty  to  animals  (gouging  out  their  eyes,  plucking 
the  feathers  of  birds  one  by  one,  skinning  alive  a pet  dog,  and 
laughing  loudly  the  while,  deriving  pleasure  from  its  cries  of  pain,  etc.) 
— these  are  the  principal  features  foretelling  an  anomalous  develop- 
ment of  the  affective  life. 


A school  companion  of  my  earliest  childhood — who  when 
up  was  brimful  of  goodness — used  to  amuse  himself  by  thiwwing 
barley  from  a window  of  the  house  into  the  court,  where  hens  and 
chickens  were  running  about,  and  when  they  were  gathered  together 
would  throw  down  some  large  stones  that  he  had  collected  before- 
hand, in  order  to  procure  the  great  pleasure  of  seeing  one  or  more 
of  them  in  agony ; the  offence  was  aggravated  by  the  fact  that 
the  chickens  did  not  belong  to  his  family. 

Such  children  being  incapable  of  fixing  their  attention  on  the 
lessons  in  school,  make  themselves  conspicuous  by  their  continual 
absences,  preferring  vagabondage  and  association  with  gangs  of  the 
most  brazen-faced  and  debased  characters,  with  whom  they  pass 
hours  on  end,  playing  cards  and  other  games.  There  is  complete 
absence  of  a sense  of  shame  for  the  sorry  figure  they  cut  at 
school,  and  they  excuse  their  conduct  with  vulgar  lies  ; they 
are  never  animated  by  any  feeling  of  emulation  in  their  work  : in 
most  instances  they  assume  a threatening  and  aggressive  attitude 
towards  the  teacher  when  he  makes  any  complaints,  and  among 
their  companions  they  assume  an  air  of  cynical  bravado  for  the 


486 


PSYCHIATRY 


agreeable  hours  they  have  passed  in  amusement.  If  perchance 
they  are  irritated  by  their  companions  or  teachers,  they  stand  up 
for  their  rights  with  violence.  At  home  they  are  undisciplined  : 
they  refuse  to  go  regularly  to  school,  to  the  office,  or  to  their  work  ; 
they  are  late  in  retiring  at  night ; they  ill-treat  their  own  brothers 
and  sisters,  and  in  the  superabundance  of  their  egoism  show  com- 
plete absence  of  affection  for  their  parents,  to  whom  they  cause  all 
manner  of  pain. 

Meanwhile  the  sexual  instinct  breaks  forth  in  all  its  potency, 
with  its  train  of  attendants,  assuming  the  supreme  sway  in  the 
vital  sphere.  In  some  instances  this  sexual  ascendancy  occurs 
very  early.  Such  inferior  beings  abandon  themselves  without  re- 
straint to  onanism,  or  even  as  children  make  animal  attempts  at 
copulation  (a  restless  and  violent  neuropathic  child  of  little  more 
than  three  years  attempted  several  times  to  give  vent  to  his  las- 
civious desires  by  seizing  hold  of  the  leg  of  his  young  aunt).  They 
seek  out  women  of  evil  life,  associate  with  the  most  depraved  and 
dangerous  beings,  and  become  enamoured  of  women  who,  again, 
are  protected  by  men  of  evil  life,  to  whom  they  are  a source  of  in- 
come. Such  is  the  nature  of  their  environment,  to  which  they 
dedicate  all  the  perversity  of  their  minds.  At  this  point  we  must 
make  a distinction  between  adolescents  belonging  to  the  aristocracy 
and  the  well-to-do  citizens  and  those  of  the  working  and  common 
classes.  The  former  are  continually  obtaining  money  from  their 
families  by  all  sorts  of  violence,  steal  everything  within  their  reach, 
obtain  false  keys  of  their  parents’  cash-box,  even  menace  their 
fathers  or  mothers  with  weapons,  or,  threatening  to  commit  suicide, 
yell  and  shout  like  persons  possessed  until  they  are  given  the  whole 
or  part  of  the  desired  sum  which  is  to  serve  for  their  debaucheries 
with  their  women  and  the  associates  of  the  latter,  in  whose  hands 
the  young  delinquent  is  now  a mere  tool  ; or,  if  his  family  is  rich 
and  he  is  to  inherit  a fortune,  he  will  sign  bills  of  exchange  which 
are  five  or  ten  times  the  value  of  the  money  received.  Sometimes 
such  degenerates  will  forge  the  signatures  of  their  fathers  or  mothers  ; 
and  so,  in  their  revelry  and  the  delirium  of  their  senses,  they  squander 
their  fortunes  and  those  of  their  families  without  regret  ; they  com- 
promise their  liberty  without  giving  it  a thought ; they  are  without 
chastity,  without  repentance,  without  sorrow^,  and  without  pity  for 
their  poor  parents,  whom  they  hate,  and  whose  death  they  desire. 
The  most  barefaced  cynicism,  the  most  complete  and  profound 
moral  anaesthesia,  the  most  serene  ignorance  of  their  social  duties, 
their  future,  and  the  misery  threatening  them,  are  amongst  their 
characteristics  ; or  even  if  they  recognise  the  danger,  like  an  inevit- 
able fatality  overhanging  them  and  swaying  their  destinies,  they 
give  no  sign  of  active  repentance  or  awakening  of  good  desires. 
Stupefied  by  enjoyment  and  by  the  environment,  they  reach  that 
extreme  limit  of  economic  potentiality,  where  await  them  the  con- 


delinquency  487 

tempt  and  the  ill-treatment  of  those  very  beings  who  have  drained 
their  last  drop  of  blood  and  destroyed  any  germ  they  may  have 
possessed  of  the  sentiment  of  honour. 

Those  belonging  to  the  lowest  social  strata  at  an  early  age  give 
themselves  up  to  an  evil  life,  associate  with  professional  thieves 
and  assassins, \nd  pursue  their  career,  passing  through  the  different 
grades  of  delinquency,  according  to  their  dexterity  and  audacity 
and  their  ferocity  in  aggressions.  If  sent  to  an  ordinary  house  of 
correction  they  show  themselves  more  apt  pupils  in  perversity 
than  in  improving  themselves  and  learning  to  work.  They  are 
always  cynical  and  extraordinarily  cruel,  especially  in  youth. 
Dril  {La  criminalite  et  les  crimmels,  1895)  refers  to  a youth  of  sixteen 
years  whose  lascivious  desires  were  greatly  excited  by  the  mistress 
of  a workman  who  had  adopted  him  and  brought  him  up.  This 
woman  fell  ill,  and  during  her  illness  was  killed  and  ravished  by 
that  youth,  who  afterwards  recounted  the  story  of  his  crime  with 
horrible  cynicism  : ‘ When  I happened  to  touch  her  skin  I was 
overwhelmed  by  the  desire  to  possess  her,  and  feeling  myself  greatly 
excited  at  the  sight  of  her  superb  neck,  said  to  myself : “ I shall  have 
her,  dead  or  alive  !”  As,  however,  I thought  I would  not  be  able  to 
obtain  her  consent,  the  idea  came  into  my  head  to  kill  her  and  then 
satisfy  my  desires  to  the  full ; it  would  be  so  nice  whilst  the  body 
was  yet  warm  !’ 

At  seventeen  years  of  age  Caruson,  according  to  a prearranged 
plan,  cut  the  throat  of  an  old  lady  who  had  been  good  to  him.  In  the 
presence  of  the  reeking  body  he  made  a search  for,  and  took  posses- 
sion of,  everything  of  value  she  possessed,  then  coolly  went  away 
as  if  he  had  done  nothing  at  all  serious.  In  prison  or  without,  such 
individuals  seek  the  company  of  adults  hardened  to  a life  of  crime, 
and  become  enchanted  with  tne  new  and  grotesque  horizons  opened 
out  before  them  ; they  become  fanatical  in  their  hope  or  determina- 
tion to  give  a sudden  proof  of  their  valour,  their  courage,  theii 
audacity.  They  are  full  of  aspirations  to  reach  the  highest  grades 
of  their  society  ; the  last  feeble  remains  of  their  repugnance  for 
crime,  if  ever  it  existed,  is  swept  away ; in  crime  is  their  very  exist- 
ence, love,  honour,  vanity,  and  joy  ; the  pleasure  they  find  in  a 
society  inimical  to  the  generality  of  men,  whom  they  cause  all  sorts 
of  anno}^ance  and  unforeseen  danger,  is  the  end  of  their  existence. 
Some  nourish  a deadly  hatred  for  their  parents,  especially  if  the 
latter  make  efforts  to  restrain  them  from  their  perverse  tendencies  , 
others,  who  either  have  no  homes  or  have  no  homes  to  which  they 
can  go,  have  a hatred  for  the  city  police,  who  represent  the  only 
obstacle  to  their  evil  designs.  If  warned,  they  strongly  resent 
being  shadowed  and  watched  by  the  police,  against  whom  they 
cherish  ideas  of  revenge,  which  explode  with  an  extraordinary 
violence  on  an  attempt  at  arrest.  The  outburst  of  fury  is  then 
terrific,  with  its  mingled  threats  and  abuses,  so  that  it  requires 


488 


PSYCHIATRY 


three  or  four  to  apply  the  handcuffs.  This  state  of  affairs  some- 
times continues  even  in  the  police  cell,  and,  wrongly  interpreted 
by  the  authorities  and  the  police  surgeon,  leads  to  the  offender 
being  sent  to  the  asylum  instead  of  to  the  prison.  Immediately 
they  come  into  the  asylum  a state  of  calm  supervenes.  On  two 
occasions  when  warders  arrived  at  the  asylum  to  transfer  a de- 
linquent of  this  class  to  the  police  cell  or  to  prison,  the  very  sight 
of  them  was  sufficient  to  immediately  excite  in  the  offenders  a state 
of  fury,  accompanied  by  obscene  language,  yelling,  kicking,  and 
struggling,  so  that  it  became  necessary  to  detain  them  longer  in 
• the  asylum  in  order  to  persuade  them  to  exercise  some  self-restraint 
in  their  own  interests. 

They  are  addicted  to  the  use  of  wine,  which  they  tolerate  badly. 
Small  quantities  of  wine  or  any  alcoholic  liquor  have  an  extra- 
ordinary influence  in  exciting  them  to  crime  (Lombroso).  Misdea, 
the  soldier  Radice,  Caruson,  and  many  other  born  or  habitual 
criminals,  committed  their  crimes  under  the  influence  of  drink. 

They  have  a tendency  to  league  themselves  together  in  gangs — 
e.g.,  the  ‘ Camorra,’  the  ‘ Maffia,’  and  the  ‘ Teppia  the  same  thing 
happens  in  the  asylum  unless  they  are  kept  under  close  observa- 
tion and  isolated  from  one  another.  They  have  common  interests, 
means,  and  methods,  and  feel  the  need  of  reciprocity  of  protection. 
The  individual  members  of  a clique  never  abandon  one  another  ; 
when  taken  into  custody  their  companions  often  provide  for  their 
better  treatment  in  prison  and  for  the  wants  of  their  families  ; they 
are  very  obedient  to  the  statutes  and  regulations  of  the  particular 
society  to  which  they  belong.  This  holds  good  everywhere.  What 
I have  noted  has  been  observed  also  by  Dostojewski,  Orfanoff, 
J andrintzeff.  No  virtue  has  any  value  in  their  eyes  ; they  recog- 
nise, esteem,  and  appreciate  nothing  but  brute  force. 

They  are  a society  apart,  and  take  a pride  in  their  force  and 
potency  in  crime. 

Strong  or  not,  they  are  pervaded  by  a great  vanity,  which  is 
a real  weakness  (Lombroso).  Everyone  remembers  the  morbid 
vanity  of  Musolino,  who  was  less  concerned  about  his  ultimate  fate 
than  about  what  the  Italian  journals  said  of  him.  He  was 
exceedingly  courteous,  especially  with  the  correspondents  of  the 
journals,  and  it  was  to  them  he  most  frequently  turned  when 
from  the  dock  he  replied  to  the  President  of  the  Court  of  Assize. 

The  sentiment  of  remorse  is  entirely  absent.  They  lie  in  the 
most  barefaced  manner ; they  almost  invariably  pose  as  the  victims 
of  injustice  and  persecution  ; when  they  have  committed  murders 
they  even  feel  that  they  were  justified  in  doing  so.  No  matter  what 
their  nationality,  these  delinquents  one  and  all  present  the  same 
traits.  Dostojewski  says  : ‘ During  the  long  years  of  my  deten- 
tion, I never  once  observed  in  the  convicts  the  least  sign  of  re- 
pentance or  of  regret  for  the  crimes  committed.’ 


489 


DELINQUENCY 

Impulsiveness  is  another  characteristic  of  this  group  of  delin- 
quents. A slight  opposition  is  sufficient  to  excite  them  to  reaction  ; 
then  they  burst  out,  making  ferocious  attacks.  Others  curb  their 
anger,  and  make  a cowardly  attack  on  their  enemies  when  their 
backs  are  turned.  Good  dissimulators,  they  sometimes  know 
how  to  wait  for  the  opportune  moment,  so  as  to  insure  success  in 
carrying  out  their  evil  projects. 

They  are  emotional  to  an  extraordinary  degree.  I reproduce 
here  some  tracings  taken  on  Musolino  with  the  gauntlet  of  Patrizi 
(Figs.  71  to  75). 

They  are  cruel  to  their  lovers,  whom  they  beat,  even  slashing 
their  faces  with  razors.  From  time  to  time,  almost  periodically,  this 
impulsive  tendency  breaks  forth,  and  is  a truly  morbid,  emotive 
superexcitability,  almost  maniacal  and  accessional.  This  feature, 
common  amongst  Italian  criminals,  has  also  been  observed  by 
Dostojewski,  as  mentioned  by  Kowalewski.  According  to  him, 
there  exists  a type  of  delinquent  ordinarily  very  quiet  and  calm. 
Such  a one  supports  the  bitterness  of  his  lot  without  the  least  com- 
plaint, only  to  burst  out  some  day  or  other  ; then,  the  time  being 
ripe,  without  a moment’s  warning,  he  strikes  down  his  oppressor. 
Having  once  killed  his  enemy — and  he  understands  the  nature  of 
his  act,  since  he  sees  the  need  of  an  apparent  pretext — the  same 
convict  continues  his  murderous  assaults.  He  does  not  confine 
himself  to  his  enemies,  but  kills  the  first  person  he  meets,  kills  for 
amusement,  because  of  a word  of  doubtful  meaning,  a look  on  which 
he  puts  a bad  interpretation,  etc.  It  is  impossible  to  foresee  such 
an  explosion,  which  in  prison  is  sometimes  of  a collective  nature, 
and  presents  the  same  characteristics  in  all  countries. 

In  ordinary  asylums,  such  as  that  of  Naples,  where  there  does 
not  exist  a special  department  for  them,  they  maltreat  the  poor 
mental  weaklings,  striking  terror  into  their  hearts,  and  even  de- 
priving them  of  any  extra  they  receive  from  their  relatives — e.g., 
tobacco  or  money.  Some  of  them  have  taken  really  indefatigable 
interest  in  many  of  the  patients,  without  any  thought  of  direct 
profit  ; but  it  is  only  to  secure  the  goodwill  of  the  superintendent  or 
the  physicians,  and  to  obtain  greater  advantages  through  them,  and 
finally  their  freedom,  as  soon  as  they  deem  it  opportune  to  return  to 
their  ordinary  life,  only  to  resume  with  eagerness  and  delight  their 
criminal  adventures. 

Many  have  true  periods  of  calm,  in  which  they  are  fairly  well 
disciplined  and  respectful.  After  a certain  time,  however,  the 
mania  for  crime  returns  with  overpowering  and  determinative 
strength,  with  a periodicity  that  resembles  that  of  other  instincts. 
Some  of  them  not  only  kill  but  torture  their  victims. 

They  are  often  religious  and  given  to  flattery,  but,  like  epileptics, 
they  pass  from  flattery  to  cruel  violence  at  a moment’s  notice, 
either  in  reaction  against  a real  or  supposed  injury  or  to  attain 


490 


PSYCHIATRY 


some  hidden  end.  Al]  the  criminals  confined  in  my  asylum  have, 
before  me  and  the  medical  officers,  exhibited  marked  subjection  ; 


Fig.  71. — Accused  of  Theft.  Acquittal. 


Fig.  72. — When  Musolino  remembered  his  Enemy  Zoccoli. 


Fig.  73.— When  Musolino  remembered  his  Sweetheart. 


Fig.  74. — When  Musolino  remembered  his  Sister. 


Fig.  75. — When  he  was  again  reminded  of  his  Enemies. 

to  me  they  have  shown  humility  for  the  simple  reason  that  from 
me  they  have  obtained  some  concession,  and  hope  to  get  their 
liberty  as  soon  as  they  are  tired  of  asylum  life  and  begin  to  make 


DELINQUENCY 


491 


entreaties  to  be  discharged  as  recovered.  As,  however,  from  time 
to  time,  I declare  those  who  are  not  insane  (belonging  to  Group  IV.) 
to  be  responsible  to  the  judicial  authorities,  when  they  see  that 
they  are  condemned  on  the  strength  of  my  report,  they  seek  to 
intimidate  me  in  order  to  escape  punishment  and  the  special  vigi- 
lance of  the  police.  The  simulation  of  insanity  or  of  epilepsy  is 
one  of  the  most  striking  features  in  Neapolitan  criminals.  In 
Italian  tribunals,  owing  to  the  exaggeration,  from  a professional 
point  of  view,  of  the  bearing  of  the  doctrines  of  the  Italian  anthropo- 
logical school,  a certain  number  of  criminals  have  been  liberated  in 
consideration  of  the  morbid  origin  of  the  crime,  as  has  also  happened 
with  some  epileptics  who  have  committed  grave  crimes.  The  result 
of  all  this  has  been  that  delinquents  have  learned,  in  prison  and 
then  in  the  asylum,  to  simulate  epilepsy  and  mental  confusion  in  a 
wonderfully  perfect  manner.  One  such  individual  brought  on  a 
convulsive  attack  during  the  clinical  lecture  I was  delivering  upon 
him  apropos  of  simulation,  reproducing  all  the  classical  phenomena 
of  the  epileptic  attack,  even  cyanosis  (voluntarily  stopping 
respiration  in  the  expiratory  phase)  and  bloody  froth  in  the 
mouth. 

They  are  revengeful  in  the  extreme.  On  one  occasion  one  of 
them  attacked  a head  attendant  when  his  back  was  turned,  and, 
with  a small,  sharp  piece  of  glass,  managed  to  inflict  a long  wound 
on  his  face,  and  this  owing  merely  to  the  fact  that  he  had  rigidly 
carried  out  the  orders  given  him  with  regard  to  the  patient,  whom 
he  had  kept  well  under  control. 

They  are  lazy  and  indifferent  (Lombroso,  Ferrero,  Dostojewski, 
Laurent,  Fere,  Kowalewski,  and  others).  They  work  readily  on 
their  own  initiative  and  in  accordance  with  their  fancies,  in  order 
to  attain  a given  end  or  to  procure  some  advantage,  as  when  they 
assist  the  nurses  in  looking  after  the  patients,  or  in  the  distribution 
of  the  food,  of  which  they  always  take  the  lion’s  share,  or  when 
they  go  to  work  in  the  garden  or  in  the  kitchen,  sometimes  to  meet 
someone  whom  they  can  domineer,  at  other  times  to  procure  a 
weapon — a piece  of  glass,  a nail,  or  a splinter  of  wood — witli  which 
to  attack  a chosen  enemy.  All  of  them  have  ever  the  greatest 
repugnance  to  an  arranged,  continuous,  disciplined  form  of  labour, 
proportioned  to  their  strength. 

Pederasty  is  frequent  among  them,  both  active  and  passive, 
according  to  their  character. 

Their  intelligence  is  almost  always  below  the  average  ; the  per- 
ceptive power  is  weak,  the  memory  unfaithful  ; through  force  of 
their  lying  habits,  they  confound  truth  with  falsehood  ; the  imagina- 
tion is  poor  in  resource. 

Some  of  them  are  dreamers  by  nature,  have  the  aesthetic  sense 
somewhat  more  developed,  and  write  emphatic  verses  ; their 
passional  and  mystic  verse  resembles  the  poetry  of  primitive 


492 


PSYCHIATRY 


peoples.  A classic  example  is  found  in  the  poetry  of  Musolino  (La 
Biografia  di  un  handito,  Morselli  and  De  Sanctis,  1903). 

The  ideative  field  is  almost  invariably  restricted  to  that  which 
refers  to  their  individual  interests.  Astuteness  takes  the  place  of 
intelligence. 

I here  report  a typical  case  of  a born  criminal. 


Observation. — G.  E.,  son  of  the  late  L.  and  the  surviving  widow  A., 
on  the  17th  day  of  September,  1903,  in  the  Via  Paolo  Emilo  Imbriani, 
stripped  himself  naked,  tearing  his  clothes  into  pieces  and  publicly 
exposing  his  genitals.  He  was  arrested  and  conveyed  to  prison  to  answer 
a charge  of  indecent  conduct.  As  this  was  not  the  first  occasion  on  which 
G.  had  abandoned  himself  to  similar  acts,  having,  in  point  of  fact,  only 
been  discharged  from  prison  the  previous  day,  after  undergoing  a sentence 
of  forty  days  for  the  very  same  indecency,  and  as  the  previous  history 
of  G.  showed  that  for  over  twenty  years  his  life  had  been  spent  alternately 
in  the  prison  and  the  asylum,  the  suspicion  arose  that  this  act  whereby 
he  made  an  exhibition  of  himself  was  not  a conscious  and  voluntary  act, 
but  was  rather  to  be  regarded  as  an  effect  of  mental  disorder. 

G.  E.,  a native  of  Naples,  age  forty-three  years,  is  of  low  stature,  has 
a rather  delicate  complexion  and  somewhat  feeble  health,  owing  to 
chronic  bronchitis,  with  frequent  exacerbations.  He  presents  numerous 
degenerative  anthropological  signs,  of  which  the  following  are  most 
worthy  of  consideration  : a not  very  marked  degree  of  plagiocephaly 
and  scaphocephaly ; very  marked  prominence  of  the  external  semi- 
circular line  of  the  occipital  bone ; nose  large  and  slightly  deviated  to  the 
left  ; strongly  developed  lop  ears  ; Darwin’s  tubercle  more  developed 
on  the  left  side.  (I  omit  the  measurements  of  the  cranium  and  the  face, 
as  they  present  nothing  remarkable.) 

He  bears  also  numerous  tattoo  marks,  signs  of  the  society  of  which 
he  is  a member,  and  a record  of  the  very  many  days  spent  in  prison. 
On  the  left  arm,  round  the  figure  of  a revolver,  is  inscribed : ‘ With  this, 
whilst  there  is  life,  there  is  hope.'  On  the  right  arm  is  written  : ‘ Long 
live  the  Republic  ! ’ On  the  dorsal  aspect  of  the  left  forearm  are  these 
words  : ‘ I loved  Sylvia  of  Constance,  and  she  returned  my  love  ; now  she 
is  dead,  I will  love  no  more.' 

The  examination  of  the  thoracic  and  abdominal  organs  reveals  no 
noteworthy  feature  apart  from  signs  of  chronic  bronchitis.  The  physical 
examination  of  the  nervous  system  reveals  accentuation  of  the  patellar 
reflexes  and  diminished  sensibility  to  pain.  Eor  the  rest,  there  is  nothing 
abnormal. 

The  psychic  condition  of  G.  E.  is  to  be  gathered  not  so  much  from  the 
actual  examination  as  from  his  history,  which  furnishes  us  with  such 
particulars  that,  with  their  guidance,  it  is  impossible  to  fall  into  any 
error  as  regards  the  mental  structure  of  our  subject. 

First  of  all,  let  us  inquire  into  the  nature  of  his  family  environment. 
His  father  belonged  to  a family  in  fairly  good  circumstances.  Between 
1848  and  i860  he  became  a member  of  a secret  society  having  patriotic 
objects  in  view,  and  took  part  in  some  insurrectionary  movement  in  the 
southern  provinces.  For  this  he  was  prosecuted  by  the  Bourbon  Govern- 
ment, and  for  four  years  was  an  exile  in  foreign  lands,  unable  for  a long 
time  to  communicate  with  his  family.  At  the  end  of  four  years  he 
unexpectedly  arrived  home  one  night,  to  the  great  surprise  of  his  family. 
As  it  was  impossible  to  remain  concealed  in  a small  country,  where  sooner 
or  later  he  must  inevitably  be  discovered,  he  presented  himself  to  the 
Duke  di  S.  V.,  a great  friend  of  Ferdinand  II.,  with  the  object  of  inducing 


DELINQUENCY 


493 


the  Duke  to  obtain  for  him  the  King’s  pardon.  The  Duke  obtained  the 
pardon,  and,  afterwards,  even  gave  him  a daughter  in  marriage.  There- 
after, L.,  having  married  a lady  much  richer  than  himself,  and  belonging 
to  a higher  social  class,  became  exceedingly  inflated  in  his  manners. 
He  left  his  modest  residence  and  came  to  Naples  to  live  in  pomp  and 
magnificence,  and  his  luxurious  apartments,  his  carriages,  liveries,  and 
insensate  expenditure  very  soon  resulted  in  the  dissipation  of  the  young 
couple’s  patrimony.  L.  had  no  time  to  change  his  mode  of  life  or  to 
experience  poverty,  for,  having  joined  the  patriotic  conspiracies,  he  was 
killed  in  the  reactionary  movement  on  September  4th,  i860,  leaving  his 
young  wife  with  a baby  at  the  breast  and  soon  to  bear  another.  Our 
patient,  G.  E.,  was  the  firstborn. 

The  father,  then,  was  an  exalted  fanatic,  a spendthrift,  perhaps  even 
a scoundrel.  On  the  death  of  her  husband  the  mother  of  G.  E.  bore  her 
misfortune  with  grief  more  apparent  than  real.  It  is  inadvantageous  to 
occupy  ourselves  with  her,  except  to  show  that  the  germ  of  delinquency 
was  not  wanting  even  on  her  side.  Her  second  child,  born  after  the  death 
of  her  husband,  remained  with  her  almost  until  maturity  ; the  first, 
however,  from  a very  early  age,  lived  almost  constantly  with  relatives, 
and  occasionally  in  his  mother’s  house.  We  shall  see  what  sort  of  life  he 
led  when  grown  up. 

Such  were  the  parents  of  our  patient : the  father  ill-balanced,  fanatical, 
and  prodigal  ; of  the  moral  character  of  the  mother  the  son  himself  speaks. 

The  earliest  years  of  G.  E.’s  life  are  outlined  in  a remarkable  document 
in  our  possession.  During  his  last  detention  in  the  provincial  asylum 
at  Naples  he  wrote,  at  our  request,  and  in  order  to  employ  himself  in 
the  long  hours  of  idleness,  his  biography — a document  of  more  than 
ordinary  interest,  in  which  he  reveals,  with  satisfaction  and  with  absolute 
frankness,  the  earliest  appearance,  the  gradual  growth,  and  the  immense 
development  of  his  low,  unrestrainable  instincts  in  the  midst  of  the 
arid  desert  of  his  mind,  void  of  moral  sentiments.  It  is  a writing  which, 
if  we  make  allowance  for  errors  in  spelling,  poverty  of  language,  and 
dialectic  constructions,  features  compatible  with  his  total  lack  of  culture, 
absorbs  the  interest  of  the  reader  who  is  not  indifferent  to  the  problems 
of  psychopathology,  and  commands  the  attention  from  the  first  to  the 
last  line.  Though  the  reader’s  mind  be  perturbed  on  being  admitted 
to  the  hidden  secrets  of  a perverse  mind,  where  the  criteria  of  ordinary 
life  are  reversed;  where  brute  instinct  reigns  supreme  without  any  con- 
trast of  criteria  and  of  moral  sentiments,  yet  at  least  it  is  pleased  and 
surprised  by  the  sincerity  with  which  the  author  reveals  himself.  It  is 
wonderful,  indeed,  to  note  how  a man  who  cannot  possibly  have  been 
taught  by  anyone  to  trace  the  genesis  of  ideas,  sentiments,  and  passions, 
follows  the  gradual  development  of  his  tendency  to  theft,  a tendency 
which  ultimately  becomes  unrestrainable.  I mention  the  headings 
merely  of  some  chapters  in  which  he  deals  more  particularly  with  this 
tendency  : ‘ The  Little  Thief — E.’s  First  Theft — First  Arrest — First  Trial 
— The  Camorristal  Society  in  the  Cappuccinelle  of  Naples — Admission  of 
No.  918  [that  was  his  number  on  the  register]  to  the  Circle  of  picciuotti 
[young  hands] — The  Admonition — ^The  House  of  Correction.’  These 
headings  clearly  indicate  the  successive  stations  along  the  road  to  de- 
linquency. He  commences  with  a trivial  theft  at  home,  instigated  by 
his  companions  ; the  theft  is  discovered  by  mere  accident  and  reported 
to  the  police  authorities  by  the  family,  whose  suspicions  had  fallen  on 
innocent  persons.  He  arrives  at  the  theft  of  1,800  lirse  from  two  ladies 
in  broad  daylight  on  the  Ponte  della  Sanita,  accomplished  entirely 
without  aid.  Thenceforward  he  commits  innumerable  petty  robberies 
of  varying  magnitude,  sometimes  being  discovered  and  punished,  at 
others  evading  discovery.  Now  he  is  involved  in  some  petty  thefts 


494 


PSYCHIATRY 


attempted  or  committed  by  himself  alone,  now  he  is  the  central  figure  in 
a society  of  robbers  ; again,  he  is  simply  an  accomplice,  playing  a secon- 
dary part ; his  handiwork  is  in  constant  evidence  ; when  there  is  an  evil 
deed  to  be  done  he  is  sure  to  have  a hand  in  it. 

Proceeding  in  an  orderly  fashion,  however,  I might  first  mention  that 
as  a child  he  was  cruel  and  given  to  stealing.  He  himself  writes  : ‘ G.  E., 
arrived  at  the  age  of  seven  years,  became  so  cruel  and  ferocious  that  his 
aunt  was  unable  to  exercise  any  corrective  influence  over  him,  notwith- 
standing the  punishments  she  inflicted  upon  him  each  time  she  had 
complaints  from  the  mothers  of  other  boys  whom  E.,  without  any  reason, 
habitually  ill-treated,  striking  them  or  scratching  their  faces  with  his 
finger-nails,  or  even  stabbing  them  ; at  times  when  he  could  find  no  boys 
to  ill-use,  he  would  climb  trees,  take  young  birds  from  their  nests,  and, 
without  a care  for  their  sufferings,  pluck  their  feathers  and  wring  their 
necks,  all  with  the  greatest  enjoyment.  Besides  these  perverse  qualities, 
which  show  him  to  have  been  a heartless  wretch,  he  exhibited  another, 
even  more  significant  one,  which  compelled  his  aunt  to  keep  under  lock 
and  key  all  linen  articles,  money,  etc.,  for  everything  that  came  within 
his  reach  he  stole.  . . . Notwithstanding  all  these  very  bad  qualities  of 
G.  E.,  he  was  greatly  loved  by  a charming  creature,  who  could  not  tear 
herself  away  from  him  for  a single  moment.  She  was  his  cousin,  his  aunt’s 
daughter.  Every  time  the  aunt  punished  her  nephew  by  keeping  him 
without  food,  this  cousin  concealed  the  half  of  her  dinner,  conveyed  it 
secretly  to  him,  and  consoled  him  with  affectionate  caresses.  Whilst 
she  loved  her  cousin,  he  hated  her,  used  to  strike  her,  and  sometimes 
tried  to  violate  her.’ 

Thus  he  describes  the  cruelty,  the  tendency  to  steal,  and  the  precocious 
development  of  the  sexual  instinct,  and  no  more  faithful  description  could 
be  given. 

With  the  lapse  of  years  these  wicked  tendencies,  far  from  becoming 
checked,  grew  ever  stronger.  At  eight  years  of  age,  when  he  used  to 
sleep  alone  with  his  cousin,  he  embraced  her  and  held  her  tightly  in  his 
grasp,  and  only  failed  to  violate  her  because  of  the  insufficient  develop- 
ment of  the  sexual  organs,  but  enjoyed  the  genital  orgasm.  Later  on, 
at  nine  years  of  age,  he  stole  some  money  from  his  aunt’s  house  and  went 
with  some  companions  to  a neighbouring  country  fair,  where  he  had  a 
true  copulation  with  a woman  connected  with  the  show.  A few  days 
afterwards  he  noticed  that  he  had  been  infected  with  blenorrhcea.  A year 
or  so  later,  having  returned  to  his  mother’s  house,  he  violated  his  brother, 
a boy  of  seven  years.  He  next  devoted  his  attentions  to  prostitutes, 
one  of  whom,  at  one  time  a singer  in  the  Teatro  delle  Follie  Drammatiche, 
made  him  her  lover,  providing  him  with  food  and  drink  and  giving  him 
pocket-money  for  his  vices.  Thenceforward  he  showed  no  further 
homosexual  tendencies,  and  had  recourse  to  sodomy  only  in  prison,  in 
the  absence  of  women. 

At  the  age  of  eleven  or  twelve  years,  having  been  sent  to  the  house  of 
correction  of  the  Cappuccinelle,  he  was  thrown  into  contact  with  the 
organized  ‘ Societa  Camorristale,’  and  was  soon  admitted  a member. 
He  was  initiated  into  the  rules  of  the  society  by  an  older  companion, 
underwent  examination,  and  became  a picciuotto.  Very  soon  he  dis- 
tinguished himself  among  the  members  of  the  society  by  his  dexterity 
in  theft,  and  was  looked  up  to  by  his  companions.  Some  years  later, 
after  a bloody  crime,  greatly  desired  and  boldly  executed,  he  was  pro- 
moted to  be  a camorrista.  In  the  criminal  asylum  at  Aversa,  in  various 
lu'isons,  in  the  house  of  correction  in  Ischia,  he  unfailingly  found  the 
‘ organized  circle  ’ of  picciiiotti  or  of  camorristi,  and  joined  their  num- 
ber ; on  some  occasions  he  has  even  acted  as  chief,  when  no  more  con- 
spicuous person  than  himself  was  present.  Outside  the  prison  or  the 


DELINQUENCY  495 

asylum  he  always  remained  faithful  to  the  oath  taken  before  the  head 
'picciuoUo  of  the  Cappuccinelle. 

His  speciality  is  pocket-picking.  He  has  not  involved  himself  to 
any  great  extent  in  bloody  crimes.  Only  two  persons  has  he  persecuted 
with  an  implacable  hatred,  and  even  attempted  to  kill.  These,  he  himself 
affirms,  were  his  mother’s  lover  and  a certain  other  person  who,  for  a 
small  sum,  acquired  from  his  mother  his  paternal  patrimony,  which  she  had 
no  right  to  sell.  This  person  on  one  occasion  only  escaped  his  fury  and 
his  dagger  by  the  ready  intervention  of  some  people  who  stepped  between 
them.  Against  his  mother’s  lover  for  many  years  he  meditated  revenge, 
having  sworn  on  the  portrait  of  his  father  to  vindicate  the  injured  honour 
of  the  family.  Finally,  he  waited  for  him  one  morning  on  the  Piazza 
Municipio  and  discharged  a pistol  at  him,  wounding  him  severely  in  the 
shoulder.  The  court  of  assize  acquitted  him.  He  has  committed  no  other 
bloody  crime. 

To  an  individual  who  so  frequently  fell  into  the  hands  of  the  police, 
it  was  necessary  to  invent  some  means  or  other  of  eluding  punishment 
as  far  as  possible  ; and  G.  E.  found  it  in  the  simulation  of  insanity.  He 
confesses  that  the  first  occasion  on  which  he  attempted  simulation  was 
when  they  proposed  to  discharge  him  from  the  Cappuccinelle,  when  he 
feigned  epileptic  convulsions  and  insanity.  His  first  deception  having 
proved  successful,  he  repeated  it  frequently,  always  with  happy  results. 
It  was  only  a few  years  ago,  in  this  provincial  asylum,  that  the  deception 
was  discovered  and  denounced.  The  convulsion  simulated  by  G.  E.  so 
closely  resembled  the  real  typical  epileptic  accession  that  on  one  occasion 
I made  use  of  G.  E.  to  demxonstrate  to  my  students  how  difficult,  and  some- 
times almost  impossible,  it  is  to  determine  with  certainty  whether  an 
accession  be  feigned  or  real.  G.  E.  now  confesses  his  deception  with  the 
greatest  unconcern,  and  with  the  same  effrontery  with  which  he  admits 
all  his  roguery. 

Erom  this  analysis  we  can  readily  deduce  that  it  is  not  the  exact  and 
rapid  perception  of  things,  not  the  power  of  reasoning,  nor  the  discrimina- 
tion of  right  from  wrong,  that  is  wanting  in  our  subject;  it  is,  rather, 
the  altruistic  sentiments  that  are  defective. 

The  sentiment  of  love,  which,  being  in  immediate  relation  with  the 
sexual  instinct,  of  which  it  is  merely  an  evolved  stage,  should  thrill  his 
mind,  is  almost  entirely  silent.  As  a child,  in  the  birthplace  of  his  family, 
he  took  advantage  of  the  puerile  affection  of  a little  girl  of  his  own  age 
who  was  enamoured  of  him  to  derive  particular  favours,  and  in  order 
to  vent  upon  her  the  precocious  instincts  that  were  arising  within  him. 

When,  however,  after  a prolonged  separation,  she  again  met  him, 
now  a marriageable  young  man,  and  the  old  love  kindled  anew  in  her’ 
he  showed  himself  proof  against  all  the  innocent  seductions  she  employed 
to  win  him  to  her.  To  one  letter  full  of  affection  which  that  creature  sent 
to  him,  he,  after  some  expressions  of  regard,  replied  thus  : ‘ My  heart 
is  not  made  to  love,  and  I could  never  make  you  happy.’  It  is  true, 
however,  that  he  had  some  esteem,  and  perhaps  even  a little  affection 
—a  rare  thing  ! — for  Sylvia.  ‘ How  could  I make  you  happy,’  he  wrote, 
‘ in  the  career  upon  which  I have  entered— that  of  a camorrista—onQ 
which  could  only  bring  you  afflictions  innumerable  and  a sea  of  tears, 
seeing  that  I am  sure  to  end  my  days  in  penal  servitude  or  die  a violent 
death  ?’ 

Sylvia’s  love  for  him  was  strong  enough  to  redeem  him  had  he  been 
capable  of  redemption.  In  consequence  of  this  ill-requited  love  and  the 
rumours  she  heard  of  the  crimes  and  misdeeds  of  her  lover,  she  died  of 
consumption  at  the  age  of  twenty.  The  sacrifice  of  this  lady  and  the 
consciousness  that  he  was  unworthy  of  her  love  have  left  a sad  memory 
in  his  mind.  The  name  of  Sylvia,  as  we  have  already  seen,  figures  in 


496 


PSYCHIATRY 


one  of  the  tattoo  marks,  with  words  and  designs  that  rise  above  the 
affective  capacity  of  our  subject.  Thereafter  he  attached  himself  only 
to  women  who  gave  him  the  fruits  of  prostitution. 

He  has  no  religious  sentiment.  He  writes  of  his  religion  as  follows  : 
‘ I never  did  and  do  not  yet  believe  in  the  existence  of  God,  for  all  human 
beings  are  born  of  chance  and  nature.’ 

We  see  in  him  only  his  ego,  cruel,  ruthless,  irreconcilable,  instinctive. 
The  moral  sentiment  is  not  even  rudimentary.  He  finds  pleasure  in 
causing  injury  to  others  ; the  sight  of  his  fellow-beings  or  of  animals  in 
pain  gives  him  a keen  satisfaction  ; other  people’s  property  is  his  ; he 
recognises  no  law  outside  that  of  the  camorristal  society.  No  disturb- 
ance of  the  intellect  is  discernible  in  him  ; no  defect  of  logic  is  present 
in  the  ideative  process,  nor  can  we  discover  any  quantitative  or  quali- 
tative defect  in  the  perceptive  process.  He  is  cunning,  with  that  shrewd- 
ness that  constrains  the  intellect  to  immobility  (Jolly,  Krause,  Wey — 
‘ Physical  and  Intellectual  Training  of  Criminals  ’).  He  has  never  suffered 
from  any  mental  disorder,  nor  from  epilepsy.  Any  condition  of  that  kind 
that  was  at  one  time  attributed  to  him,  and  that  led  to  his  being  sent  to 
the  asylum  and  thus  acquitted  or  found  irresponsible  for  his  crime,  was 
always  feigned.  Like  all  born  criminals  and  criminals  from  acquired 
habit,  he  obeys  a permanent  tendency. 

Such  is  the  picture  of  this  criminal.  The  bilateral  psychopathic 
heredity,  the  degenerative  anthropological  signs,  and  the  hypoalgesia, 
are  his  distinguishing  biological  features.  The  psychology  of  G.  E.  gives 
us  a general  idea  of  the  ruling  features  of  the  born  criminal. 

Delinquency  in  woman  assumes  diverse  forms  and  character- 
istics, depending  upon  the  structure  of  her  mind,  upon  her  nature 
and  her  tendencies,  in  a word — upon  her  character.  Weaker  in 
moral  sentiment,  more  vindictive,  more  jealous,  more  vain,  and  at 
the  same  time  less  courageous,  than  man,  she,  as  a rule,  takes  a 
second  place  as  an  accomplice  of  the  male  delinquent,  either  inciting 
to  crime  or  acting  as  a receiver  of  stolen  goods.  She  is  less  fre- 
quently homicidal  than  man,  and  prefers  poison  to  a dagger  ; she 
is  oftener  a thief  and  infanticide,  but  is  less  intelligent,  less  wary, 
and  has  less  foresight,  leaving  more  evident  traces  of  her  work. 
For  some  time  back  the  number  of  crimes  committed  by  women 
with  the  revolver  has  been  on  the  increase. 

The  centre  of  irradiation  of  the  tendencies  and  actions  of 
woman  lies  in  her  sexual  life — love  and  jealousy.  To  overcome 
obstacles  or  get  rid  of  dangers  in  the  attainment  of  her  ends,  in  the 
satisfaction  of  her  instincts,  and  in  the  abandonment  of  her  mind 
to  her  passions  is,  as  a rule,  the  motive  of  the  crimes  of  the 
female  delinquent.  Lascivious  and  fanatical,  she  is  an  incongruous 
mixture  of  love  and  hatred,  of  generosity  and  avarice,  of  sympathy 
and  cruelty,  of  piety  and  sinfulness.  More  readily  swayed  by  passion 
than  man,  she  allows  herself  to  be  carried  away  by  the  impetus  of 
her  mind  with  rather  less  precaution,  and  in  her  criminal  projects 
does  not  hesitate  in  the  selection  of  the  line  of  conduct  by  which 
she  gives  effect  to  her  passionate  state — theft,  homicide,  infanti- 
cide, abandonment  of  the  f amity,  and  prostitution.  The  multi- 
plicity of  the  crimes  is  the  expression  of  her  mobile  and  readily 


DELINQUENCY 


497 


decomposable  nature  (Lombroso  and  Ferrero,  Tarnovski,  Kowa- 
lewski).  Less  modest  than  man,  but  more  able  to  simulate,  she 
yields  herself  to  the  demands  of  sexuality,  which  easily  rend  the 
thin  veil  of  chastity  and  honour,  and  on  this  account  she  is  more 
prone  to  exhibitionism  and  obscenity. 

The  great  bulk  of  female  delinquency  is  manifested  in  prostitu- 
tion. There  the  primitive  instinct,  stripped  of  all  the  vestments 
of  the  cultured  mind,  finds  free  course  ; there  we  behold  the  unre- 
strained brutality  of  pleasure  with  all  its  perversions  ; there  is  dealt 
the  death-blow  of  all  that  love  can  give  to,  or  receive  from,  the 
intellect  and  character. 

The  born  prostitute  manifests  her  nature  and  her  instinctive 
sexual  tendencies  from  adolescence  or  an  early  age.  She  yields 
herself  without  reflection  to  the  overpowering  demands  of  the 
sexual  instinct.  In  these  and  other  characteristics  the  born  pros- 
titute resembles  the  born  delinquent  (Lombroso  and  Ferrero). 

But  the  born  prostitute  is  very  rare.  The  majority  of  prosti- 
tutes are  made  so  by  poverty  or  as  the  result  of  seduction.  After 
the  first  downward  step,  expelled  from  home,  obliged  to  leave 
their  own  district,  they  give  themselves  up  to  an  evil  life,  and  drown 
their  remorse  in  orgies  of  love  and  debauches  of  alcohol ; it  is  a kind 
of  immoral  alienation. 

Such  women,  if  placed  under  favourable  conditions,  may  yet 
become  good  wives  and  even  good  mothers.  I have  had  oppor- 
tunity of  following  the  histories  of  several  of  them  whom  I had 
under  treatment  in  the  hospital  for  syphilitic  affections  at  the 
beginning  of  my  career ; sexual  ansesthesis  is  frequent  even  in 
these. 

Somatic  signs  of  degeneration  are  less  marked  in  woman  than 
in  man. 

There  are  few  differences  with  regard  to  functional  disorders. 
These  are  often  of  a hysterical  nature. 

.Etiology. — The  causes  of  delinquency  are  many  ; I will  men- 
tion only  the  principal. 

Psychopathic  Heredity — Primitive  Constitution. — They  belong  to 
races,  regions,  and  social  ranks  in  which  the  conditions  for  a 
proportionate  development  of  the  moral  sentiment  are  unfavour- 
able. Jealousy,  hatred,  suspicion,  revenge,  individualism,  prejudice, 
cruelty,  are  their  predominant  mental  features. 

Civilization. — It  is  well  known  that  the  more  urgent  require- 
ments of  life  drive  to  crime  those  weaker  individuals  who  endeavour 
to  procure  the  necessaries  of  life  with  the  least  possible  exertion. 
This  universal  phenomenon  is  portrayed  in  the  most  vivid  colours 
by  Zola  in  the  character  of  Nanette  in  ‘ Travail.’  The  increase  in 
delinquency  in  all  civilized  countries  is  dependent  upon  the  com- 
plicated social  relations,  which  demand,  proportionately  to  the 

32 


498 


PSYCHIATRY 


increased  desires  and  requirements,  a higher  potential  of  individual 
energy  to  overcome  obstacles.  It  is  clear  that,  if  the  development 
of  the  reactive  energies  is  not  proportionate  to  the  amount  of  labour 
demanded  by  the  exigencies  of  modern  civilized  life,  there  is  an 
increase  in  the  proportion  of  weaklings  who  cater  for  their  existence 
by  deviating  from  the  lines  laid  down  by  general  consent.  All 
the  more  must  the  number  of  those  less  adapted  for  the  perform- 
ance of  the  functions  of  such  complicated  mechanisms  increase, 
the  less  the  mind  is  prepared  for  the  new  conditions  of  existence, 
provided  there  do  not  exist  circumstances  so  favourable  as  to  induce 
in  a race  a rapid  evolution  of  the  cerebral  activities  proportionate 
to  the  complication  of  the  mechanisms  of  the  social  life.  Without 
doubt  the  enormous  increase  of  delinquency  in  many  regions  of 
modern  Italy  is  to  be  attributed  to  a want  of  preparation  for  the 
forms  of  modern  civilized  life. 

The  progress  of  civilization  gives  not  only  an  increase  in  insanity, 
but  also,  in  the  weaker  or  younger  races,  an  increase  in  delinquency. 
The  massing  together  of  large  numbers  of  workmen  in  industrial 
centres,  with  the  consequent  increase  of  the  sum  of  desires  and 
aspirations,  alcoholism,  depraved  habits,  and  syphilis,  give  rise 
to  degeneration  and  thus  to  delinquency. 

Education  and  the  press,  especially  the  latter,  by  raising  the 
individual  consciousness  and  tending  to  level  all  social  classes, 
offer  to  the  poor  and  weak  m a highly  attractive  form,  a daily 
quotum  of  desires  destined  to  remain  unsatisfied. 

Religion,  the  sentiment  of  which  is  every  day  becoming 
weaker  with  the  diminishing  faith  in  the  joys  of  a future  life  that 
rendered  the  misery,  griefs,  and  hardships  of  this  earthly  life  more 
tolerable,  plays  also  its  part.  Religion,  if  it  is  not  morality,  is 
at  least  a step  towards  true  morality,  for  which  humanity  is  slowly 
but  surely  preparing  itself.  The  strong  inhibitory  power  that 
religion  was  wont  to  exercise  is  now  becoming  weaker  much 
more  rapidly  than  the  sentiment  of  human  solidarity,  and  the  con- 
sciousness of  individual  duty  are  developing. 

Politics  and  Public  Administration,  and  the  vast  held  that  the 
new  liberties  open  to  citizens  in  the  management  of  public  affairs, 
the  passions  and  the  interests  connected  therewith,  give  the  measure 
of  the  moral  weakness  of  a great  number  of  individuals,  and  add  a 
signihcant  cipher  to  the  delinquency  of  those  countries  with  a free 
government. 

Prisons  exercise  a great  influence  for  evil  in  the  matter  of  de- 
linquency, by  gathering  together  children  and  adolescents.  In  one 
of  my  speeches  in  the  House  of  Deputies  I had  occasion  to  say  that 
the  prisons  were  a school  for  delinquency.  Dril  conhrms  my  obser- 
vation. Kowalewski  asserts  that  in  Russia,  thanks  to  the  indolence 
of  the  State,  more  than  10,000  adolescents  are  each  year  made 
depraved  and  prepared  for  a career  of  crime  b\^  the  lessons  received 


DELINQUENCY 


499 


in  prisons.  Of  140,000  imprisoned  annually  in  France,  129,000 
return  to  society  more  depraved  than  before  (Virouboff).  Twenty- 
two  per  cent,  of  prisoners  liberated  return  to  the  Russian  prisons 
every  year. 

It  is  beyond  doubt  that  even  the  school  sometimes  produces 
criminals.  In  those  that  are  greatly  crowded  it  is  sufficient  for 
the  spread  of  evil  that  there  be  two  or  three  who,  during  the  hours 
of  recreation,  make  active  and  efficacious  propaganda  of  their 
instincts  and  criminal  tendencies,  which  find  in  youth  and  in 
adolescence  a ready  and  fertile  soil  (Emminghaus,  Tard). 

Alcohol  has  a great  genetic  power, ^ot  only  in  delinquency  in 
general,  but  in  innate  criminality.  In  this  respect  there  holds  good 
what  we  have  already  said  as  regards  the  aetiology  of  phrenasthenia, 
besides  what  we  have  yet  to  add  with  respect  to  the  aetiology  of 
epilepsy.  Crimes  due  to  alcohol  reach  an  enormous  figure — 
according  to  Baer,  41-5  per  cent.  ; according  to  Claude,  45  per  cent, 
in  France  ; in  Hungary,  35  per  cent.  (Feketin)  ; in  Switzerland, 
42  per  cent.  (Schaffrot)  ; in  Sweden,  71  per  cent,  of  men  (Wiesel- 
gren)  ; in  the  district  of  St.  Petersburg,  47  per  cent.  (Kowalewski). 

Poverty  is  certainly  one  of  the  most  potent  causes  of  delinquency. 

To  be  in  comfortable  circumstances  is  to  be  well  armed  against 
criminality.  Good  nutrition,  satisfaction  of  the  real  requirements 
of  life,  education,  and  proportionate  labour,  are  all  factors  facili- 
tating the  maintenance  of  equilibrium  in  the  development  of  the 
brain,  and  the  proper  adaptation  of  the  individual  to  the  environ- 
ment. Poverty,  bringing  in  its  train  scanty  nutrition,  urgent 
needs  that  remain  unsatisfied,  and  insufficient  dwellings,  where 
sexual  contacts  are  easy  and  premature ; numerous  progeny,  which, 
as  F.  S.  Nitti  has  demonstrated,  is  an  accompaniment  of  misery  ; 
hard  labour  in  the  mine,  in  the  workshop,  or  in  the  fields,  where, 
as  in  the  scholastic  communities,  the  presence  of  one  or  two  badly 
disposed  individuals  is  sufficient  to  make  proselytes  to  criminality  ; 
and  drunkenness,  in  which  it  is  sought  to  drown  the  weariness  or 
sorrow  of  life  for  a few  hours,  and  the  prostitution  resulting  there- 
from, are  all  factors  that  give  rise  to  degeneration  and  delinquency 
in  the  descendants. 

On  the  other  hand,  wealth  may  also  supply  a good  contingent 
to  degeneration,  owing  to  the  unrestrained  indulgence  in  carnal 
pleasures  on  the  part  of  the  sons  of  rich  parents,  who  have  been 
brought  up  in  the  lap  of  luxury,  and  have  had  all  their  desires 
gratified  indiscriminately  and  without  opposition.  Perhaps  no 
one  has  described  better  than  Zola,  in  his  picture  of  the  decadence 
of  the  Quirignon  family,  the  progressive  degeneration  of  the  rich 
(Bianchi,  Conferenza  su  Zola). 

Age  is  not  without  its  influence  in  delinquency.  Youth  is  more 
favourable  than  maturity  to  criminality.  Tard  appears  to  have 
found  an  increase  in  the  number  of  young  and  a diminution  in  the 

32—2 


500 


PSYCHIATRY 


number  of  mature  homicides.  In  Germany  the  increase  of  51  por 
cent,  of  the  delinquents  that  took  place  in  the  years  prior  to  1898 
was  in  great  measure  due,  according  to  Hirsch,  to  the  increased 
number  of  young  criminals.  The  explanation  is  evident.  De- 
fective education,  want  of  religious  restraint  (Tard),  strong  desire 
and  impatience  for  the  pleasures  of  life,  vigour,  vanity  and  thought- 
lessness, strong  sexual  instinct,  the  weak  sentiment  of  authority 
(which  every  day  is  growing  weaker)  in  the  family,  the  State  and 
the  Church,  the  morbidly  exalted  and  hypertrophied  sentiment  of 
equality  in  young  men  in  whom  it  arises  from  the  sentiment  of 
personal  energy  when  uncorrected  by  a good  and  vigilant  upbringing 
—all  concur  towards  the  greater  frequency  of  criminality  in  the 
young.  The  child  is  per  se  a delinquent  as  compared  with  the  adult, 
only  the  natural  process  of  evolution-  and  education  make  it  a useful 
member  of  society. 

Commange,  physician-in-chief  at  Saint  Lazare’s  at  Paris,  adduces 
in  his  book  on  prostitution  astounding  figures  bearing  upon  the  large 
number  of  clandestine  prostitutes  who  have  contracted  syphilis 
before  the  age  of  eighteen. 

Once  criminality,  or,  in  the  wider  sense,  degeneration,  is  initiated 
in  the  family,  the  latter  becomes  a nursery  of  candidates  for  de- 
linquency. Heredity  gives  the  criminal  disposition,  and  example 
the  criminal  education  ; poverty  and  alcohol  remove  from  the 
consciousness  of  the  delinquent  or  the  degenerate  any  lurking  good 
that  might  yet  be  found  therein.  Alcohol  and  insanity  come  under 
the  same  heading  in  criminal  heredity.  The  publications  of  Lom- 
broso,  Penta,  Virgilio,  Marro,  and  others,  exhibit  in  the  clearest 
possible  light  the  close  relationship  between  insanity  and  delin- 
quency. The  born  criminal  inherits  the  disposition  to  crime,  which 
may  be  corrected  by  favourable  circumstances.  In  this  regard 
the  theory  of  Lombroso  is  very  probable.  I exclude  the  organic 
fatality  of  crime,  except  where  the  congenital  disposition  towards 
delinquency  is  complicated  with  epilepsy.  I hasten,  however,  to 
declare  that  it  is  not  at  all  just  to  increase  the  too  general  belief 
with  regard  to  the  frequency  of  the  association  of  epilepsy  with 
congenital  delinquency,  if  we  do  not  wish  to  confound  epilepsy 
with  impulsivity,  very  different  pathological  factors,  because  it 
has  very  frequently  happened,  especially  since  the  doctrine  of 
the  Italian  positive  school  has  become  popular,  that  in  the 
public  prosecutions,  epilepsy,  in  either  the  convulsive  or  the 
psychic  form,  has  been  simulated  by  criminals  in  a marvellous 
manner. 

It  is  certain  that  early  attention  to  the  upbringing  of  the  chil- 
dren of  criminals  gives  marvellous  results,  even  when  the  presence 
of  anthropological  signs  gives  evidence  of  the  organic  structure  of 
the  born  criminal.  Hence  the  hereditary  born  criminal  may  develop 
in  one  of  two  directions  : he  either  remains  in  the  criminal  environ- 


DELINQUENCY 


501 


merit,  a poor,  depraved  creature,  with  the  result  that  his  innate 
criminality  becomes  reinforced,  or  he  finds  an  educative  environ- 
ment and  becomes  a respectable  member  of  society,  a corrected 
criminal,  or  a criminal oid.  In  this  case  the  biological  (Bechterew), 
the  moral,  and  the  intellectual  sides  all  undergo  a modification  ; 
the  prenatal  instinct  of  an  antisocial  life  is  efficiently  restrained  by 
the  new  acquisitions  from  the  mind  of  humanity  ; the  new  grafts 
from  the  great  tree  of  life  yield  fruit  that  is  acceptable  to  civilized 
humanity ; or,  again,  he  may  become  a modernized  delinquent,  very 
egoistic  and  very  cunning,  striving  to  hide  under  a polished  exterior 
his  primitive  covetous  nature  and  his  evil  designs  on  the  posses- 
sions of  others. 

Whilst  the  psychopathic  heredity  gives  the  born  delinquent, 
who  is  reinforced  by  the  environment,  the  environment  alone  may 
give  rise  to  the  criminal  from  acquired  habit,  who  is  with  great 
difficulty  to  be  distinguished  from  the  born  criminal.  In  his  case 
also  we  have  the  handiwork  of  poverty,  faulty  nutrition,  ill-lit  and 
badly- ventilated  houses,  rickets  and  aniemia  in  infancy,  then  evil 
example  in  the  family  (type,  Couteau-Gervasia),  prostitution, 
alcoholism,  debauchery,  incest,  ill-treatment,  hunger,  the  instiga- 
tion to  theft  that  the  children  receive  from  depraved  and  unfeeling 
parents,  so  that  they  also  become  wicked  and  insensate,  impudent, 
impulsive,  troublesome,  assuming  a hostile  attitude  towards  every- 
thing that  is  extraneous  to  themselves — e.g.,  enjoyment,  good 
breeding,  order,  discipline.  It  is  in  this  way  that  criminality  may 
have  its  origin  in  social  conditions  and  become  a matter  of  habit. 
The  delinquent  from  habit  also  presents  signs  of  anomalous  evolu- 
tion (anthropological  stigmata  of  degeneration  are  not  rare),  evi- 
dences of  rickets,  hyponutrition  and  diseases  of  infancy,  and  it  is 
very  difficult  to  distinguish  him  from  the  true  born  delinquent. 
The  ‘ Camorra  ’ in  Naples  and  the  ‘ Teppia  ’ in  Milan  are  respon- 
sible for  the  creation  of  criminal  habits,  the  former  to  a very  great 
extent,  the  latter  within  narrow  limits. 

The  born  criminals  ally  themselves  with  this  association  of  evil- 
doers, finding  therein  the  conditions  for  a complete  adaptation. 
The  two  groups  resemble  one  another  in  form  and  in  their  anti- 
social manifestations,  and  are  distinguished  only  by  their  genesis 
and  by  the  fact  that  the  criminals  from  habit,  not  being  burdened 
by  psychopathic  heredity,  are  more  amenable  than  the  others. 

Speaking  generally,  weakness  gives  a rather  larger  contribution 
to. delinquency  than  strength. 

The  seasons  and  the  climate  have  a great  influence  upon  the 
number  and  the  nature  of  the  crimes.  In  the  North,  and  during 
our  cold  season  there  is  a prevalence  of  crimes  against  propert}^ ; 
in  the  South  and  during  the  hot  season  there  is  a prevalence  of 
crimes  affecting  persons  (Lombroso,  Penta,  Foinitsky,  Kowa- 
lewski). 


502 


PSYCHIATRY 


The  prognosis  of  delinquency  is  rather  grave.  The  born  de- 
linquent is  often  very  refractory ; nevertheless,  cases  are  not 
wanting  of  a slow  development  of  high  sentimentality.  It  is 
certainly  not  a rare  thing  for  young  delinquents  with  a pronounced 
psychopathic  hereditary  burden  and  with  all  the  features  of  the 
born  delinquent,  after  they  have  reached  the  age  of  thirty  or  forty 
years,  to  adapt  themselves  a little  better  to  the  social  environment 
and  to  live  a life  that  is  sometimes  irreproachable. 

I have  observed  some  such  cases,  and  therefore  cannot  share 
the  opinions  of  those  who  hold  the  criminality  of  the  born  de- 
linquent to  be  organic  and  incapable  of  modification. 

The  therapy  can  only  be  aetiological.  It  is  summed  up  in  a social 
legislation  that  secures  a more  vigorous  health,  efficient  labour,  and 
a more  equal  distribution  of  the  profits  of  labour  and  of  wealth, 
which  provides  a better  education,  favouring  the  development  of 
the  collective  consciousness,  which  is  becoming  substituted  for  the 
religious  consciousness,  every  day  becoming  weaker  and  less  effica- 
cious— a legislation,  in  short,  which,  changing  the  system  of 
punishment,  in  view  of  the  morbid  nature  of  the  crime,  eliminates 
one  of  the  surest  and  most  potent  causes  of  delinquency. 


CHAPTER  VI 


EPILEPTIC  INSANITY 

The  pathological  and  clinical  conceptions  of  epilepsy,  because  of 
their  lack  of  uniformity,  cannot  easily  be  given  in  an  always  recog- 
nisable descriptive  picture.  Considered  from  either  the  somatic 
or  the  psychic  side,  the  clinical  variety  is  great,  the  combination 
of  phenomena  varied  ; the  interpretation  of  the  facts  and  the 
extent  of  the  field  assigned  to  epilepsy  varies  according  to  the 
different  authorities.  While,  on  the  one  hand,  it  is  a matter  of 
dispute- as  to  whether  the  Jacksonian  form  should  be  considered 
as  epilepsy,  seeing  that  in  that  syndrome  there  is  an  entire  absence 
of  any  disturbance  of  the  consciousness  (Christian),  on  the  other 
hand  it  is  sought  to  widen  the  field  of  epilepsy  by  taking  in  moral 
insanity  and  paranoia  (Lombroso).  It  is  well,  therefore,  to  come 
to  an  understanding  on  this  point.  We  must  decide  whether  the 
essential  feature  of  epilepsy  is  a more  or  less  profound  disturbance 
of  the  consciousness,  or  whether  a senso-motor  feature  is  sufficiently 
characteristic  of  it.  In  the  first  case  we  should  have  to  eliminate 
from  the  pathological  conception  of  epilepsy  all  those  convulsive 
forms  that  are  unaccompanied  by  profound  disturbance  of  the 
consciousness  and  amnesia  ; in  the  second  case  we  should  have  to 
include  all  the  motor  or  senso-motor  explosions  in  the  widest  sense 
of  the  word,  in  which  case  would  be  included  another  group  of 
affections,  also  essentially  represented  by  motor  explosions  and 
hy  a disturbance  of  the  consciousness,  and  which,  moreover,  until 
now  have  been  considered  as  forms  quite  distinct  from  epilepsy  ; 
I refer  to  the  tics. 

Such  a conception  of  epilepsy,  whilst  it  is  wider  and  embraces 
morbid  forms  that  have  till  now  been  considered  to  be  of  another 
nature,  is  more  rational,  because,  just  as  we  cannot  exclude  from 
the  pathological  conception  of  a disease  an  aborted  syndrome 
such  as  often  occurs  as  the  prelude  to  a general  and  complete  attack, 
so  it  would  not  be  rational  to  exclude  the  tics,  which,  after  all,  are 
only  cortical  explosions,  at  one  time  senso-motor  or  ideo-motor, 
but  now  withdrawn  from  the  directive  power  of  the  consciousness. 

503 


504 


PSYCHIATRY 


They  flourish  in  that  very  soil  of  incomplete  evolution  from  which 
epilepsy  also  emanates,  and  in  their  syndromes  we  frequently  find 
the  psychic  characteristic  which  we  shall  describe  as  peculiar  to 
epilepsy. 

It  is  useless  to  eliminate  the  Jacksonian  syndrome  from  the 
conception  of  epilepsy,  because  if  it  is  true  that  it  is  due  most 
often  to  traumata,  or  to  circumscribed  organic  processes  operating 
in  loco  and  in  no  way  altering  the  psychic  personality,  it  is  also 
true  that  in  many  cases  the  Jacksonian  syndrome  is  the  first,  often 
brief,  phase  of  the  classic  epileptic  accession — that  is  to  say,  it 
is  the  beginning  of  an  explosion  which,  not  being  under  any  regu- 
lative and  balancing  influence  of  other  regions  of  the  brain,  influence 
which  should  be  exerted  through  the  associative  paths,  becomes 
directed  along  the  projection-paths,  giving  rise  to  the  convulsion. 
The  pathological  importance  of  the  explosion  is  not  to  be  sought 
for  in  the  partial  or  general  convulsion,  which  has  no  psychiatric 
value  per  se,  but  in  the  want  of  functional  harmony,  in  the  dis- 
sociation of  the  various  cortical  provinces,  in  the  individualization 
of  one  (a  sign  of  lack  of  discipline  amongst  them),  in  the  defect  of 
that  functional  synchronism  of  the  cortex  which  is  the  best 
guarantee  of  the  energy  and  efficiency  of  the  personality. 

Looked  at  in  this  light  the  tics  appear  to  be  of  the  same  nature 
cortical  motor  explosions,  irrational  and  inefficacious,  owing  to 
individualization  of  cortical  areas,  in  rebellion  against  the  law  of 
co-ordination,  of  subordination,  and  of  association. 

The  anatomical  substratum  of  the  epileptic  does  not  furnish 
the  means  of  ready  communication  between  the  functioning  cortical 
groups,  so  that  the  tensions  accumulating  in  one  group  under  a 
great  variety  of  internal  and  external  stimuli  do  not  diffuse  and 
spread  themselves  over  neighbouring  or  distant  groups,  but  dis- 
charge themselves  through  the  emissive  paths,  which  are  much 
ampler  and  more  pervious,  because  older  and  in  longer  use.  It  is 
to  this  fact  that  we  must  look  for  the  reason  of  the  place  assigned 
to  epilepsy  in  the  classification  of  the  psychoses.  The  irascibility 
and  the  impulsiveness  which  we  recognise  as  the  most  classic 
features  of  the  psychology  of  the  epileptic  are,  after  ah,  the  effect 
of  the  disproportion  between  the  ample  and  facile  paths  of  pro- 
jection and  the  narrow,  less  numerous  and  less  practicable  paths 
of  association.  Thus  are  rendered  possible  the  high  tensions  which 
discharge  themselves,  under  inadequate  and  disproportionate 
stimuli,  by  the  primitive  motor  paths  (including  those  of  the  vaso- 
motor nerves)  and  by  the  simpler  motor  co-ordinations — viz., 
those  expressing  anger  and  those  by  which  the  epileptic  performs 
actions  bearing  the  character  of  simplicity  and  of  primitivity, 
owing  to  defect  of  association.  They  therefore  cause  injury,  more 
or  less  serious,  depending  upon  the  disproportion  between  the 
weak  associative  power  of  the  brain  of  the  epileptic  and  the  associa- 


EPILEPTIC  INSANITY 


505 


tive  power,  which  is  also  regulative  and  moderating,  of  the  brains 
of  the  group  to  which  the  epileptic  belongs. 

The  reason  for  the  preference  which,  in  my  opinion,  must  be 
given  to  the  dynamic  doctrine  of  epilepsy  is  now  evident.  Epilepsy 
is  connected  with  the  asymmetries  that  are  met  with  in  the  cranium 
and  the  brain.  Asymmetries  are  also  very  frequent  in  the  face — • 
e.g.,  deviations  of  the  nose  (Tonnini,  Ganel,  Fere)  ; in  the  colour 
of  the  irides  (Roncoroni,  De  Boni  and  Dotto,  Fere)  ; in  the  innerva- 
tion of  the  internal  and  external  ocular  muscles  (Bianchi) ; in  the 
thorax  (Zuccarelli)  ; and  in  the  hands  (Vielle).  Asymmetry  is 
present  in  the  function  of  the  eyes  (the  frequency  of  astigmatism 
along  with  plagiocephaly  has  been  noted  by  De  Boni  and  Dotto), 
and  in  the  function  of  the  upper  limbs  (left-handedness  : a,  motor — 
Tonnini,  Lombroso,  Roncoroni,  Fere,  and  Bianchi  ; h,  sensory — 
Venturi  and  Tonnini). 

The  epilepsy  which  so  frequently  develops  in  maturity  in  those 
who  in  their  infancy  had  irreparably  lost  the  use  of  a limb  owing 
to  acute  anterior  poliomyelitis,  which  in  the  course  of  years  induces 
an  arrest  of  development  in  the  corresponding  cortical  zone  ; the 
epilepsy  which  so  frequently  arises  as  the  result  of  destructive 
foci  in  the  brain,  or  of  the  pressure  and  displacement  caused  by 
tumours,  or  of  inflammatory  processes  that  destroy  the  centres 
and  paths  and  interrupt  currents  ; the  epilepsy  so  frequent  in  those 
who  suffer  from  spasmodic  logoneurosis  (stammering),  are  all 
facts  supporting  the  hypothesis  that  in  the  epileptic  the  anatomical 
substratum  consists  of  the  unequal  development  of  centres  and 
paths,  rendering  possible  a high  tension  in  some  regions  of  the  cortex 
or  in  the  subcortical  centres,  and  hence  the  nervous  explosions 
which  characterize  this  great  neurosis  in  all  its  forms. 

After  many  years  of  continuous  observation  I am  still  more 
convinced  of  the  truth  of  the  conception  I expressed  concisely 
in  the  chapter  on  Epilepsy  in  the  Italian  Trattato  di  Patologia  e 
Terapia  Medicale  (vol.  ii.,  part  4,  Bianchi  and  Colucci) — viz.,  that 
asymmetry  is  the  most  constant  and  the  most  characteristic  feature 
of  epilepsy  both  in  the  anatomical  and  morphological  and  in  the 
psychic  field. 

The  w^hole  of  the  material  gleaned  from  observation,  which 
numerous  researches  have  accumulated  with  the  view  of  consoli- 
dating the  pathology  of  epilepsy  and  determining  its  immediate 
cause,  is  composed  of  consecutive  facts,  of  the  ultimate  effects 
of  the  repeated  accessions  of  neurosis,  and  hence  we  can  get  no  light 
shed  upon  the  mechanism  of  epilepsy  from  this  examination. 

As  regards  its  physiopathology,  epilepsy  is  associated  with  a 
state  of  cerebral  superexcitabihty,  which  varies  in  different  indi- 
viduals through  intrinsic  conditions  of  the  central  nervous  system- 
On  experimenting  with  well-regulated  strengths  of  the  faradic 
current  on  the  cerebral  cortex  of  animals  not  under  the  influence 


5o6 


PSYCHIATRY 


of  chloroform  and  under  presumably  equal  conditions,  in  some 
cases  convulsions  appear  very  soon,  in  others  only  after  very  many 
momentary  excitations.  A natural  difference  in  the  degree  of 
excitability  exists  between  the  different  cortical  zones,  as,  e.g.,  in 
the  dog,  between  the  sigmoid  gyrus  and  the  visual  area  on  the 
posterior  part  of  the  second  external  convolution.  .The  time 
necessary  for  the  production  of  convulsions  by  direct  excita- 
tion of  the  motor  cortex  is  much  shorter  than  that  required  by 
excitation  of  the  occipital  lobe.  The  fact  that  in  one  dog  electrical 
excitation  of  the  visual  area  requires  a minimum  length  of  time  to 
raise  the  tension  of  the  sigmoid  gyrus  sufficiently  to  give  rise  to  a 
convulsive  attack,  whilst  in  another  we  fail  to  provoke  epilepsy 
even  with  a stimulus  of  five  times  the  intensity,  must  depend  on 
heredity  or  acquired  histo-chemical  conditions,  which  are  the 
true  organic  substratum  of  epilepsy.  We  might  reasonably  hold 
that  in  the  first  case  the  biological  (physio-anatomical)  conditions 
of  epilepsy  are  latent.  Experimental  destructive  foci  in  bitches 
give  rise  to  epilepsy  in  some  only,  not  in  all.  Epilepsy  thus  pro- 
duced is  certainly  transmitted  to  the  offspring ; on  the  other  hand, 
the  offspring  of  bitches  that  have  not  become  epileptic  as  the  result 
of  destruction  of  the  cortex  are  not  exempt  from  epilepsy,  though 
it  is  much  less  frequent.  There  is  determined,  then,  a histo- 
chemical  epileptogenic  condition  in  the  offspring  of  the  hemiplegic 
mother. 

The  epileptic  psychosis  is  of  the  same  nature:  there  is  a high 
instinctive  or  hallucinatory  potential,  which  has  no  path  along 
which  to  discharge  itself  except  that  leading  to  the  motor  zone, 
no  other  being  open.  The  instinct  is  not  normal  in  character 
nor  is  the  emotion,  which  is  always  of  a primitive  nature — fear, 
hatred,  suspicion,  and  anger  of  high  potential,  which  discharge 
themselves  through  the  short  circuits  of  blind,  violent,  and  destruc- 
tive action.  The  hallucinations  are  similar  in  character  ; they  are 
exceptionally  vivid  (high  hallucinatory  potential)  and  are  discharged 
with  violence,  causing  the  reduction  to  the  minimum  of  the  potential 
of  the  entire  cortex  and  loss  of  consciousness. 

When  we  speak  of  excito  - motor  hyper  excitability  we  merely 
make  use  of  a circumlocution.  What  is  this  hyperexcitability  ? 
It  may  be  not  only  of  the  motor  zone,  adopting  the  cortical  theory, 
held  especially  by  the  Italian  school  (Albertoni,  Luciani  and  Sep- 
pilli,  Tamburini),  and  by  others  (H.  Jackson,  Hitzig,  Rosenbach, 
Unverricht),  but  also  of  the  sensory  zones.  If  the  epilepsv  com- 
mences with  an  olfactory  or  a visual  hallucination  which  is  followed 
by  the  motor  discharge,  we  must  deduce  that  the  hyperexcitability 
resides  in  the  respective  cortical  zone,  which  lacks  paths  for  dis- 
charge into  other  parts  of  the  cerebral  mantle  except  the  cortical  or 
subcortical  motor  centres  ; in  this  case  the  nerve-waves  are  not 
tiansfoimed  into  more  complex  products,  which  can  only  occur 


EPILEPTIC  INSANITY 


507 


through  a process  of  association,  but  are  discharged  along  the 
motor  paths  as  soon  as  they  have  reached  a maximum  degree  of 
tension. 

The  intensity  and  the  violence  of  the  discharge  diminish  the 
potential  throughout  the  mantle  to  a minimum  no  longer  sufficient 
for  the  phenomena  of  consciousness. 

Whatever  the  extent  it  may  be  desirable  to  assign  to  the  con- 
ception of  epilepsy  in  this  work,  we  can  only  describe  the  mental 
disorders  more  universally  recognised  as  epileptic  in  nature,  leaving 
to  separate  chapters  those  other  syndromes  which  have  some 
relation  with  and  resemblance  to  epilepsy,  but  which  could  not  be 
embraced  in  the  conception  of  epilepsy  without  the  risk  of  giving 
rise  to  confusion  in  the  nosological  and  pathological  pictures  of 
the  affection. 

The  psychic  disturbance,  which  is  never  absent  except  in 
symptomatic  epilepsy,  consists,  at  the  beginning,  of  the  epileptic 
character.  It  is  hereditary  or  acquired  (more  frequently  the 
former),  and  manifests  itself  at  an  early  age — indeed,  almost  as  soon 
as  relations  begin  to  be  established  between  the  infant  and  the 
family  surroundings.  Dulness,  or  at  least  but  scant  brightness  of 
spirit,  as  compared  with  healthy  children  ; prolonged  and  obstinate 
fits  of  weeping  without  any  assignable  reason,  sometimes  even  giving 
rise  to  cyanosis  of  the  face  ; persistence  in  their  exaggerated  and 
capricious  desires  in  spite  of  every  good  argument  advanced  by  the 
mother  ; the  tendency  to  react  by  scratching  the  face  or  by  breaking 
some  object,  raising  the  voice  aloud  and  stamping  the  feet,  and 
sometimes  accompanying  their  pretensions  with  threats,  are  the 
principal  facts  generating  a well-founded  suspicion  that  the  char- 
acter is  developing  in  an  anomalous  (epileptic)  direction.  The 
suspicion  is  strengthened  when  nightmares  and  terrifying  dreams 
or  spontaneous  somnambulism  co-exist. 

In  the  most  favourable  cases  these  signs  undergo  improvement 
or  disappear,  and  the  child  manifests  a more  normal  adaptation 
to  the  environment  ; in  the  severest  cases  the  upbringing  and  the 
family  surroundings  exercise  little  or  no  influence  : the  morbid 
character  becomes  constantly  accentuated,  and  shows  an  egoistic 
hypertrophy  that  nothing  can  correct. 

In  childhood  and  in  adolescence  the  epileptic  character  in  one 
group  of  cases  very  closely  resembles  the  moral  character  of  the 
born  criminal ; indeed,  no  difference  can  be  detected  between  them  : 
the  same  inadaptability  to  the  environment,  the  same  preponder- 
ance of  the  individual  instinct,  the  cruelty,  the  laziness,  the  vaga- 
bondage, the  evil  life,  the  precocious  and  excessive  character  of 
the  sexual  instinct,  the  irascibility  and  impulsiveness,  are  found  in 
both.  If  at  this  age  (adolescence)  convulsions  do  not  yet  manifest 
themselves,  the  clinical  figure  is  that  of  the  born  criminal,  provided 
there  has  been  no  occurrence  of  eclampsia  during  infancy,  in  which 


5o8 


PSYCHIATRY 


case,  even  though  these  early  convulsions  are  not  repeated,  the 
character  becomes  clearly  epileptic. 

In  another  group  of  cases  the  personality  is  less  profoundly 
disturbed.  The  representatives  of  this  group  are  more  adaptable 
to  the  family  surroundings,  are  disciplined  and  correct  in  behaviour, 
go  regularly  to  school,  learn  more  or  less  satisfactorily,  sometimes 
show,  even  under  normal  conditions,  great  moral  susceptibility, 
and  attend  to  their  tasks  at  school  ; if  they  go  to  a boarding-school 
they  do  not  differ  essentially  from  the  other  scholars,  but  are 
excessively  impressionable,  suspicious,  captious,  very  easily  offended 
— by  a jest  or  a trick  of  their  companions,  or  a just  reproof 
from  the  master  ; they  are  extraordinarily  irascible,  excessive  in 
their  reactions,  and  impulsive. 

Such  a character  is  soon  exaggerated  in  the  environment  of  the 
school  and  the  boarding-house  on  account  of  the  tendency  that 
school-children  have  to  irritate  the  most  intolerant  and  the  poorest 
in  resource  amongst  them,  by  means  of  jokes,  witticisms,  and 
juvenile  tricks.  Things  arrive  at  such  a pass,  owing  to  the  impulsive- 
ness, the  destructive  violence  of  the  reaction,  the  irascibility 
and  the  threats  of  the  victim,  that  the  masters  or  the  directors  of 
the  schools  are  obliged,  apart  from  the  existence  of  convulsions, 
to  send  away  such  youths  from  the  school. 

Again,  the  sexual  instinct  sometimes  shows  a precocious  develop- 
ment, and  males  and  females  alike  abandon  themselves  to  onanism 
and  sexual  excesses,  often  in  the  most  barefaced  and  shameless 
manner.  In  this  respect  the  female  epileptic  resembles  the  prosti- 
tute of  whom  we  have  already  made  mention  in  the  preceding 
chapter. 

In  the  course  of  years,  at  the  age  of  maturity,  the  epileptic 
character  undergoes  further  modifications.  The  epileptic  isolates 
himself,  avoiding  company  and  conversation.  The  disease  weakens 
the  bonds  that  bind  him  to  the  social  world  and  strengthens  his 
inclinations  towards  things  spiritual.  He  becomes  more  religious, 
ostentatiously  obedient  to  the  rules  and  rites  of  religion.  Every 
day  he  spends  some  time  in  the  church  ; at  home  he  recites  prayers 
and  chants.  He  becomes  excessively  humble,  assuming  a very  meek 
and  submissive  attitude  when  he  meets  any  of  his  acquaintances. 
The  consciousness  of  his  own  inferiority  to  other  men  gives  him 
an  expression  of  humility  and  reverence.  Beneath  the  surface, 
however,  he  is  often  a captious,  irascible,  violent,  impulsive,  cruel 
being.  A slight  stimulus  is  sometimes  sufficient  to  make  him 
throw  off  the  mask  of  humility  and  religion,  and  there,  stripped  of 
all  disguise,  in  all  its  hideous  nudity,  stands  revealed  the  irritated 
beast,  with  bared  fangs  and  outspread  claws. 

Irascibility  and  impulsiveness,  then,  are  the  chief  features  of 
the  epileptic  personality  ; epileptics  lose  control  of  themselves  on 
the  least  opposition.  The  inhibitory  powers  are  but  slightly 


EPILEPTIC  INSANITY 


509 


developed.  Violent  and  obstinate  in  their  desires,  which  are  too 
overpowering  for  them  to  resist,  they  appear  egoistic  in  the  highest 
degree.  Even  here  the  defect  in  the  associative  work  of  their 
brains  is  evident.  Their  malicious  character  is  based  on  the  two 
fundamental  sentiments  predominant  in  the  epileptic — viz.,  sus- 
picion and  hatred  of  their  kind  (primitive  emotions,  arising  from 
their  inferiority  with  respect  to  other  people,  inferiority  of  which 
the  epileptic  is  often  more  or  less  conscious),  along  with  contrariness 
and  permanent  irritability  of  the  proper  ego.  The  whole  life  of 
the  epileptic  shows  hatred,  which,  under  ordinary  conditions,  is 
concealed,  and  even  veneered  with  good  temper,  but  bursts  forth 
in  all  its  brutality  on  the  slightest  provocation  ; the  horrid,  the 
brutal,  all  that  is  evil,  destruction  and  death,  are  present  in  his 
mind,  though  not  evident  on  the  surface. 

The  sentiment  of  religion  in  epileptics  is  of  a primitive  nature. 
They  are  more  mystic  than  religious,  and  observe  practices  rather 
than  commandments.  With  their  minds  full  of  prejudices,  they 
exhibit  in  their  conduct  the  most  outstanding  paradoxes  in  the 
way  of  delinquency,  alcoholic  excess,  onanism,  and  other  sexual 
perversions. 

The  father  of  Misdea,  who  was  not  subject  to  epileptic  con- 
vulsions, but  showed  the  most  pronounced  features  of  the  epileptic 
character,  used  to  blaspheme  under  the  statue  of  the  Madonna 
or  of  Christ  during  the  procession  in  the  chapel  every  time  the 
members  of  the  brotherhood  did  not  walk  in  proper  order,  or  did 
not  carry  out  to  the  letter  the  instructions  he  had  given  with  regard 
to  the  procession  of  which  he  was  the  director  (Virgilio). 

Sometimes  they  are  vain  and  proud,  and  in  this  affective 
exaltation  lies  the  germ  of  true  paranoia  of  grandeur,  just  as  in 
suspicion  lies  that  of  paranoia  of  persecution. 

They  are  fond  of  wine,  and  become  more  brutal  after  drinking 
even  a small  quantity.  It  is  then  that  they  show  themselves 
most  exacting,  egoistic,  captious,  obscene,  cynical,  impulsive,  and 
cruel.  It  is  on  account  of  this  remarkable  mobility  and  these 
strange  contrasts  that  we  even  speak  of  double  consciousness. 
Lombroso  speaks  of  ‘ the  epileptic  individual  formed  by  the  union 
of  two  halves  of  different  personalities,’  and  Fere  says,  ‘ The  char- 
acter of  epileptics  is  essentially  mobile  and  explosive.’ 

In  the  majority  of  cases  the  intelligence  is  below  the  normal. 
In  some  it  is  normal ; in  rare  cases  it  is  even  above  the  normal. 
The  physician  who  has  long  had  a wide  private  practice  can  point 
to  a number  of  epileptics  \^lio  follow  trades  and  professions,  and 
seem,  to  all  intents  and  purposes,  normal,  yet  are  not  realW  so, 
because,  although  there  is  no  true  intellectual  decadence,  the 
affective  side  of  the  mind  is  more  or  less  profoundly  altered.  Accord- 
ing to  Legrand  de  Saulle,  of  more  than  40,000  epileptics  in  France, 
only  4,000  were  confined  in  asylums  for  the  insane,  while  the  rest 


PSYCHIATRY 


510 

performed  their  family  and  social  duties.  The  same  may  be  said  of 
all  countries.  This,  however,  does  not  prove  that  the  intelligence 
of  epileptics  is,  in  the  majority  of  cases,  normal.  A great  number 
are  treated  in  their  own  homes,  troublesome  though  they  be  ; 
some  even  occupy  public  offices,  and  many  find  a refuge  in  institu- 
tions other  than  asylums.  How  many,  too,  remain  able  to  conceal 
their  suspiciousness,  their  captiousness,  their  perverted  instincts, 
their  illusions,  their  rapid  formation  of  subdelirious  ideas,  and  their 
amnesias  ! Here  I would  remark  that  I do  not  now  speak  of  that 
epilepsy  which  is  so  frequently  grafted  upon  imbecility  or  idiocy, 
nor  do  I even  allude  to  confirmed  epileptic  dementia. 

Feeble  capacity  of  attention  is  certainl}/  one  of  the  most  con- 
spicuous features,  as  proved  by  the  psychometric  investigations  of 
Tanzi,  who  showed  clearly  that  the  mean  time  of  reaction  in  the 
epileptic,  under  ordinary  conditions,  is  about  0-207  of  a second,  while 
in  normal  individuals  it  is  about  0-141  (diminished  perceptive  and 
attentive  capacity)  ; the  oscillations  of  attention  were  found,  on 
an  average,  to  be  in  the  ratio  of  3 to  2 as  compared  with  normal 
individuals. 

From  the  psychometric  investigations  carried  out  in  my  institute 
by  Dr.  Surdi  (prize  thesis),  it  is  very  evident  that  the  keenness  of 
attention  is  in  general  diminished,  and  that  in  epileptics,  dis- 
tinguishing them  from  normal  individuals,  there  is  frequently 
manifested  automatism,  or  suspension  of  the  attentive  power, 
the  duration  of  which  in  epileptics  is  reduced  to  39  seconds  as 
compared  with  an  average  of  93  seconds  in  healthy  individuals. 

Epileptics  are  often  indifferent,  torpid,  given  to  vagabondage  ; 
but  even  this  last  characteristic  sometimes  alternates  with  a degree 
of  exaltation,  during  which  they  are  more  active  and  rapid — men 
of  action,  as  we  say. 

The  intelligence  of  epileptics  in  general,  says  Tonnini  (Le 
Epilessie,  Turin,  1891),  is  limited  : the  perceptions  are  weak  ; the 
memory  is  unreliable  ; ideation  is  variable  ; grandiose  ideas  are 
frequent,  as  observed  in  Musolino,  also  ideas  of  persecution,  mysti- 
cism (paranoidism),  and  indifference  to  everything  that  does  not 
concern  them.  Lombroso  has  asserted  the  co-existence  of  genius 
with  epilepsy  in  some  cases,  and  with  his  extraordinary  acumen 
has  drawn  an  analogy  between  genius  and  epilepsy.  This  is  not 
the  place,  however,  to  enter  upon  the  discussion  of  so  delicate  and 
abstruse  a subject.  Amongst  the  many  hundred  cases  of  epilepsy 
I have  met  with  in  my  private  practice  (I  leave  out  of  account 
those  epileptics  confined  in  the  asylum,  for  in  them  mental  disturb- 
ances are  already  very  pronounced),  I have  not  found  one  of  truly 
superior  intellect.  When  we  consider  the  average  intellectual 
vigour  in  these  cases  (excluding  idiots,  imbeciles,  and  epileptic 
dements),  and  the  almost  constant  emotional  defects,  we  are  justified 
in  concluding  that  epilepsy  and  inferiority  are  two  co-existing 


EPILEPTIC  INSANITY 


511 

terms.  Genius  is  a phenomenon  which  may  coincide  and  co-exist 
with  epilepsy,  but  has  nothing  in  common  with  it. 

Of  numerous  cases  which  I might  bring  forward  in  confirmation 
of  this  synthesis  of  the  epileptic  character,  I shall  report  one  only — 
that  of  a lady  who  has  been  confined  in  the  asylum  for  more  than 
eighteen  years,  in  consequence  of  a report  presented  by  me  to  the 
magistrate.  When  first  brought  under  my  notice  she  was  a young 
epileptic  of  about  twenty-five  years  (and  now  over  forty),  pre- 
senting incomplete  evolution  (imbecility  of  a slight  degree).  On 
account  of  her  captious  and  intolerant  nature  she  was  in  continual 
hot  water  with  the  whole  neighbourhood.  On  the  morning  of  a 
holiday  she  had  a quarrel  with  a neighbour  who  had  offended  her 
by  some  trivial  but  irritating  remark.  She  became  enraged,  but 
was  able  to  restrain  herself,  or  perhaps  she  was  unable  to  retaliate 
immediately  against  her  rival,  who  was  much  the  stronger.  With 
her  mind  filled  with  hatred  and  thoughts  of  revenge,  she  waited 
until  the  other  went  to  church  to  hear  Mass,  leaving,  as  was  her 
custom,  her  baby  alone  in  the  house.  Seeing  her  opportunity, 
the  epileptic  made  a poker  red-hot,  and,  hastening  into  her  neigh- 
bour’s house,  forced  it  through  the  anus  of  the  unfortunate  child — 
a baby  of  little  more  than  three.  The  child  died  shortly  afterwards 
in  terrible  agony.  In  prison,  where  I afterwards  saw  the  offender, 
in  the  as5dum  in  which  she  has  been  confined  for  so  many  years, 
no  feeling  of  regret  has  ever  crossed  her  cynical  conscience.  The 
injury  she  had  suffered  from  the  mother  of  the  infant  well  merited 
the  grief  caused  by  the  murder  of  her  infant  daughter  ! 

As  is  apparent,  if  we  except  the  cruel  nature  of  the  crime  in 
I so  far  as  regards  means  and  form,  and  the  excessive  nature  of  the 
I reaction,  the  character  of  the  epileptic  resembles  that  of  the  born 
t criminal.  When  we  consider  that  in  the  epileptic  there  are  present 
I the  same  anthropological  degenerative  stigmata,  the  same  functional 
defects  (hypo-aesthesia,  hypo-algesia,  restriction  of  the  visual  field, 
etc.),  and  also  the  fact  that,  genetically,  the  two  branches  spring  from 
' the  same  trunk,  inasmuch  as  epileptics  and  criminals  arise  from 
degenerates,  from  the  insane,  from  delinquents,  drunkards,  and 
epileptics,  we  must  agree  that  Lombroso  was  not  wrong  in  recognising 
a great  analogy  between  the  born  delinquent  and  the  epileptic. 
It  is  to  be  noted,  however,  that  in  the  epileptic  the  moral  sentiment 
may  be  more  or  less  developed  ; but  it  is  very  unstable,  and  loses 
its  directive  power  each  time  the  ego  meets  with  opposition  or  is  sub- 
jected to  painful  stimuli.  In  epilepsy  crime  is  occasional  and 
, unforeseen  ; in  congenital  criminality  it  is  part  and  parcel  of  life. 

Epileptic  Insanity. — Besides  giving  rise  to  the  morbid  nature 
of  the  epileptic  character  just  described,  epilepsy  is  a fertile  soil 
in  which  sprout  and  live  for  a short  time  the  most  varied  forms 
of  psychosis.  Mania,  sensory  delirium,  stupor,  paranoia,  tran- 


512 


PSYCHIATRY 


sitory  insanity,  are  all  psychopathic  forms  that  arise  from  the 
epileptic  constitution  of  the  personality.  The  epileptic  syndromes, 
however,  present  somewhat  peculiar  characteristics,  by  which  they 
can  be  distinguished  from  the  genuine  forms,  so  that,  whilst  they 
certainly  resemble  the  latter,  they  have  a clinical  figure  of  their  own. 

Amidst  so  many  different  forms,  one  of  the  things  to  which  we 
may  look  for  guidance  is  the  epileptic  convulsion,  not  only  when 
immediately  related  with  the  attack  of  insanity,  but  also  in  those 
cases  where  the  psychic  disturbance  appears  to  be  independent  of 
the  convulsion,  as  in  individuals  who  have  certainly  had  epileptic 
convulsions,  but  in  a former  period  of  life.  In  this  regard  we 
meet  with  very  great  difficulties  only  when  the  patient  has  suffered 
from  convulsions  in  infancy  or  in  early  youth,  and  afterwards 
got  rid  of  them  entirely.  In  some  cases,  indeed,  we  may  fail  to 
obtain  any  history  of  convulsions.  The  greatest  number,  however, 
of  epileptic  psychoses  are  related  to  the  convulsion,  and  usually 
occur  in  subjects  who  have  suffered  from  convulsive  seizures  for 
a long  time,  and  they  either  precede  or  follow  the  convulsion,  or, 
somewhat  more  rarely,  are  substituted  for  it,  in  which  case  they 
are  termed  epileptic  equivalents,  and  such  they  are  in  the  true 
sense  of  the  word. 

In  the  majority  of  cases  the  epileptic  psychosis  manifests  itself 
in  individuals  whose  personality  has  already  assumed  the  features 
of  the  epileptic  character,  which  is  either  developmental  or  has 
gradually  been  accentuated  by  repetition  of  the  attacks. 

Considered,  then,  in  its  relation  to  the  convulsive  seizure, 
epileptic  insanity  is  distinguished  as  pre-epileptic,  post-epileptic, 
and  epileptic  equivalent,  or  masked  epilepsy. 

Pre-epileptic  insanity  in  most  instances  consists  in  the  accen- 
tuation of  the  epileptic  character.  The  patients  become,  with 
increasing  rapidity,  more  querulous,  excitable,  and  provoking, 
more  violent  and  cavilling,  more  impulsive,  garrulous,  threatening, 
and  intolerant.  The  agitation  sometimes  rises  to  such  a point  that 
they  attack  one  even  for  a word  misunderstood  or  a look  wrongly 
interpreted.  They  are  restless,  pitch  their  voices  higher  than 
usual,  shout,  swear,  and  show  destructive  tendencies.  If  they 
are  at  table  they  throw  glasses  and  bowls  about  for  a mere  nothing  ; 
break  the  slabs  with  their  fists  or  their  heads,  and  tear  their  clothes  ; 
in  their  own  homes  the  slightest  correction  or  opposition  makes 
them  curse  and  swear,  and,  if  they  get  hold  of  a stick,  they  smash 
glassware,  chandeliers,  and  dishes,  or,  if  they  are  at  dinner,  give 
a violent  pull  to  the  tablecloth,  bringing  plates,  glasses,  and  food 
to  the  floor  with  a great  crash.  Shortly  afterwards  the  convulsion 
bursts  forth. 

Others  become  gloomy,  dull,  lose  their  wonted  joviality  and 
good  humour,  avoid  company,  become  much  less  communicative, 
and  feel  themselves  oppressed,  as  though  subject  to  some  stupefying 


EPILEPTIC  INSANITY 


513 


influence  ; they  feel  the  approach  of  the  attack,  and  become  morose, 
irritated,  and  hostile  in  spirit  ; the  appetite  diminishes,  sleep  is 
broken  or  disturbed  by  the  frequency  of  terrifying  dreams  ; they 
are  often  subject  to  true  accessions  of  anguish,  with  raptus  and 
attempts  at  suicide. 

In  another  group  of  cases  hallucinations  and  deliria  are  present. 
The  hallucinations  are  of  demons,  spirits,  wild  animals,  enemies, 
blood,  wounds,  corpses,  flames,  fire,  or  else  are  of  religious  content. 

In  the  last  case  they  see  the  Madonna,  Christ,  or  saints,  as  a 
rule  in  a vengeful  attitude,  much  more  rarely  children  with  wings, 
and  angels.  Generally  speaking,  mystic  or  mundane  beauty  is  very 
rare  in  the  hallucinatory  representations  of  the  epileptic,  whose 
mental  dispositions  are  in  contrast  with  the  pleasure  afforded  by 
the  beautiful  and  the  good.  The  commonest  auditory  hallucina- 
tions are  those  of  reports  of  firearms,  buzzings,  explosions,  confused 
shouts  and  words,  insults,  threats,  the  condemning  voice  of  God 
(the  God  of  the  epileptics  is  almost  always  revengeful  and  cruel), 
or  commands  generally  of  a religious  content  ; or  there  may  be 
disgusting  olfactory  hallucinations  of  sulphur,  phosphorus,  corpses, 
and  more  rarely  of  aromatic  substances.  The  hallucinations  are 
either  single  or  multiple.  One  epileptic  always  had  the  unilateral 
hallucination  (on  the  right)  of  a black  demon  before  the  attack 
burst  forth  ; others  have  single  olfactory  hallucinations,  often  of 
identical  content.  With  the  hallucinations  there  almost  always 
coexist  a psycho-motor  agitation  of  an  impulsive  and  furious 
character  and  an  emotional  state  of  suspicion  and  malice,  giving 
rise  on  the  one  hand  to  false  judgments,  on  the  other  to  rapid, 
destructive  reaction.  Sometimes  there  is  a prevalence  of  erotic 
notions,  and  in  this  case  the  patients  abandon  themselves  to  onanism 
in  a cynical  and  barefaced  manner,  or  else  expose  their  persons 
without  the  least  sign  of  shame.  In  other  cases  we  find  a maniacal 
syndrome,  with  a happy  tone  of  mind,  which,  however,  becomes 
threatening  and  hostile  on  the  least  opposition. 

The  affective  states  and  the  restlessness  usually  last  for  some 
days,  and  in  some  cases  for  a week  and  even  longer,  whilst  the 
hallucinatory  syndromes  are  present  for  a much  shorter  time, 
sometimes  only  a few  minutes,  before  the  convulsive  explosion. 
Of  this  period  the  epileptic  preserves  no  recollection,  or  at  most  a 
very  confused  one  (crepuscular  state  of  the  consciousness). 

Whatever  the  nature  of  the  psychic  disturbance,  it  is  followed 
by  the  convulsion,  which  may  occur  during  the  night  or  in  the 
day-time,  singly  or  in  series.  The  convulsions  may  be  followed  by 
other  psychic  disturbances  ; these  may  also  manifest  themselves 
without  the  occurrence  of  an  actual  convulsive  attack. 

Post-epileptic  Insanity. — The  attack  over,  the  patient  rouses 
himself,  opens  his  eyes,  slowly  turns  his  head  round  ; his  look 

33 


514 


PSYCHIATRY 


is  uncertain,  his  manner  confused,  his  movements  slow  and  torpid. 
As  a rule  he  does  not  respond  to  commands,  but  performs  auto- 
matic movements  in  a dull  and  sleepy  manner  ; or  he  mutters  some 
words,  or  pants  weariedly,  rests  his  head  on  the  cushion,  and  falls 
into  a sleep,  during  which  he  often  snores.  When  he  awakens, 
after  some  hours,  he  is  confused,  stupid,  cannot  realize  his  present 
position  or  how  he  came  there,  does  not  recognise  the  persons 
about  him  ; he  utters  disconnected  phrases,  is  very  excitable, 
fastidious,  torpid,  and  complains  of  tiredness  and  headache  ; by 
degrees  his  mind  becomes  clearer,  and  in  a longer  or  shorter  time — 
an  hour  to  a day — he  regains  his  bearings,  and  readily  recognises 
persons  and  positions.  If  he  has  had  other  seizures  he  realizes  what 
has  happened  to  him,  although  there  remains  a blank  in  memory 
covering  a longer  or  shorter  time  antecedent  to  the  attack  ; he 
remains  for  some  hours  or  a day  more  irritable  than  usual,  and  is 
gradually  restored  completely  to  his  former  condition.  This  is 
the  simplest  form  of  post-epileptic  stupor. 

In  other  cases,  after  the  first  phase  of  stupor  or  post-convulsive 
confusion,  with  or  without  the  intervention  of  sleep,  a more  or  less 
intense  hallucinatory  delirium  breaks  out,  accompanied  by  a 
violent  destructive  motor  agitation.  His  look  is  forbidding  and 
sinister,  his  countenance  angry,  his  eyes  injected,  his  speech  excited  ; 
then  commences  a motor  agitation  in  which  he  is  troublesome, 
threatening,  noisy,  and  uproarious.  Respiration  becomes  laboured, 
the  pulse  rapid  and  full,  the  veins  of  the  forehead  turgid.  If  an 
attempt  be  made  to  restrain  him,  he  becomes  more  excited,  struggles 
violently  with  his  attendants,  conducts  himself  in  a violent  manner, 
seeks  to  make  his  escape,  to  bite,  pulls  off  his  shoes,  tears  off  his 
clothes,  snorts,  roars,  butts  with  his  head,  and  if  he  is  allowed  to 
run  free  smashes  everything  indiscriminately ; threatens,  strikes 
those  around  him,  is  homicidal  and  sometimes  suicidal.  This 
scene  may  last  several  minutes,  and  even  some  hours.  It  is  followed 
by  a dazed  and  confused  state,  which  gradually  passes  off  in  the 
course  of  one  or  several  days.  Amnesia  of  the  delirious  period 
almost  always  remains. 

In  cases  in  which  hallucinatory  delirium  is  less  intense  the 
patient  certainly  talks  and  raves,  but  shows  less  motor  agitation  and 
impulsiveness.  He  is  confused  and,  as  in  sensory  insanity,  inco- 
herent, in  accordance  with  the  visions  and  scenes  passing  through 
his  mind.  The  hallucinatory  products  become  mingled  with  new 
perceptions,  memories  and  reminiscences,  and  we  may  even  have 
chaotic  talk,  with  verbigeration  and  stereotyped  phrases.  The 
temperature  is  sometimes  raised,  the  tongue  dry,  the  breath  some- 
times penetrating  or  acetonic. 

Sometimes  the  form  is  certainly  hallucinatoiy,  but  has  a greater 
reseinblance  to  hallucinatory  paranoia  ; there  is  less  confusion  and 
disorder ; delirious  manifestations  show  a tendency  to  organization,. 


EPILEPTIC  INSANITY 


515 


and  are  of  a persecutory,  mystic-religious  (especially  in  women), 
or  grandiose  nature.  The  last  form  tends  to  be  protracted,  with 
alternations  of  comparative  calm  and  of  psycho-motor  agitation, 
never  very  intense,  and  lasting  from  a few  days  to  several  weeks.  All 
the  features  of  paranoia  may  also  be  exhibited  in  a fleeting  manner. 

In  other  cases  we  have  the  appearance  of  mania.  After  the 
first  stuporous  phase,  the  patient  becomes  comparatively  amenable 
in  behaviour,  the  tone  of  his  personality  is  raised,  he  is  more  loqua- 
cious, more  expansive,  more  active,  disturbs  those  around  him  by 
words  or  actions,  becomes  quibbling,  more  frequently  obscene,, 
shouts,  sings,  whistles,  jumps,  dances,  gyrates,  and  pushes  anyone 
who  comes  near  him  ; there  is  almost  always  a predominance  of 
hostile  feeling,  which  manifests  itself  in  threats  on  the  least  oppo- 
sition and  at  every  attempt  to  restrain  him  ; there  is  a degree  of 
maliciousness  much  higher  than  in  mania  (the  simple  psychosis). 

Sometimes  the  hostile  attitude,  with  actions  to  which  it  gives 
rise,  is  all  that  constitutes  the  picture  of  post-epileptic  insanity. 
An  example  is  as  follows  : A young  epileptic  with  criminal  ten- 
dencies is  brought  to  the  asylum  by  the  city  guards,  whom  he  insults 
with  trivial  speeches  and  provoking  epithets.  At  the  first  examina- 
tion, immediately  on  reception,  he  either  makes  no  response  or 
replies  in  a high-handed  manner,  uttering  threats  and  insults, 
swearing  revenge  on  those  who  have  brought  him  to  the  asylum, 
which  he  recognises  perfectly,  having  been  confined  here  on  a former 
occasion.  When  put  into  a single  room,  he  breaks  the  window- 
panes  with  his  fist.  On  being  put  to  bed,  he  tears  the  cover  and 
sheets,  threatens  and  insults  the  attendants.  In  his  anger  and 
irritation  he  says  he  should  not  have  been  brought  to  the  asylum, 
as  he  has  done  nothing  wrong,  and  ought  therefore  to  be  liberated. 
He  is  gloomy,  full  of  threats,  and  sometimes  refuses  food.  One 
day  he  breaks  his  bed,  and  arms  himself  with  an  iron  bar,  to  injure 
or  kill  whoever  comes  in  his  way  ; on  another  occasion  he  unhinges 
a window  and  barricades  the  door  of  his  room  ; again,  he  breaks 
the  window-panes  and  arms  himself  with  a long,  sharp  piece  of  glass, 
threatening  to  kill  someone  or  to  commit  suicide,  thus  placing  the 
whole  staff  in  a very  dangerous  and  anxious  position.  This  con- 
dition of  things  lasts  about  three  weeks,  after  which  he  is  gradually 
restored  to  his  former  condition — excitable,  captious,  violent, 
intolerant,  prone  to  criminality,  yet  at  the  same  time  reasonable, 
adaptable  to  discipline  and  work,  and  no  longer  hostile  and  threaten- 
ing. Of  all  this  period  which  followed  two  severe  convulsive 
attacks  he  has  only  a somewhat  confused  recollection  (crepuscular 
state  of  the  consciousness). 

Cases  are  met  with,  especially  in  women,  of  a post-epileptic 
syndrome  with  all  the  features  of  melancholia,  accompanied  by 
depressive,  mystic  delirium,  auto-culpability  or  demonomania. 

In  this  case  the  tone  of  mind  is  not,  as  a rule,  so  depressed  as 

33—2 


5i6 


PSYCHIATRY 


in  pure  melancholia,  nor  is  the  state  of  inhibition  so  characteristic. 
Epileptic  melancholia  is  in  most  instances  of  a loquacious  and 
somewhat  aggressive  type. 

The  Epileptic  Equivalent,  or  masked  epilepsy,  is  a mental  dis- 
turbance of  brief  and  rapid  evolution,  as  a rule  accompanied  by 
profound  disturbance  of  the  consciousness,  and  more  or  less  com- 
plete amnesia  of  the  period  of  the  duration  of  the  attack.  It 
assumes  very  different  forms  : sometimes  it  is  any  one  of  the 
psychoses  described  as  pre-  or  post-epileptic  ; the  sole  difference 
lies  in  the  fact  that  the  epileptic  convulsion  is  absent,  being  substi- 
tuted by  the  psychic  disorder.  Many  maniacal  forms  or  recurrent 
hallucinatory  psychoses  of  brief  duration,  of  which  the  respective 
patients  preserve  no  recollection,  are  epileptic  in  nature,  true 
psychic  equivalents  of  epilepsy. 

Sometimes  there  is  a precursive  seizure,  preceded  as  a rule  by 
an  intense  feeling  of  fear.  An  example  is  as  follows  : The  patient 
F.  belongs  to  a family  with  a strong  psychopathic  taint  ; he  presents 
many  anthropological  degenerative  stigmata  and  marked  stra- 
bismus, very  probably  resulting  from  eclampsia  in  infancy,  or 
from  meningo-encephalitis.  He  has  a brother  confined  in  the 
asylum  at  Sales  owing  to  severe  epilepsy  that  has  resisted  all  methods 
of  treatment.  From  time  to  time  he  is  seized  with  a strong  feeling 
of  fear  ; everything  around  him  then  seems  changed  and  alarming  ; 
the  physiognomies  of  those  around  him  appear  hostile,  and  he 
betakes  himself  to  flight,  without  knowing  whither  he  is  going.  He 
runs  fifteen,  twenty,  and  even  thirty  kilometres  without  a stop, 
ere  he  regains  his  composure.  Finding  himself  far  from  home,  he 
does  not  retrace  his  steps,  much  less  return  to  his  family,  though 
he  remembers  the  course  he  took  in  his  flight,  but  seeks  for  a means 
of  subsistence,  recollecting  with  fear  the  place  whence  he  set  out. 
An  important  feature  in  this  case  is  the  fact  that  he  preserves,  in 
the  main,  the  memory  of  the  time  of  the  attack,  with  the  most  of 
the  events  that  have  happened  to  him. 

In  some  cases  the  precursive  accession  is  entirely  unconscious  ; 
the  patient  regains  his  consciousness  in  a distant  place,  but  has 
no  notion  why  or  how  he  comes  to  be  there.  These  are  cases  of 
what  Voisin  calls  true  epileptic  flights. 

The  patient  mentioned  by  Borowkoff  (Ohosrenije  Psichiatrii, 
1899)  disappeared  from  time  to  time  for  many  hours,  and  was 
always  found  seated  in  a particular  part  of  a wood,  without  any 
recollection  of  how  he  came  to  be  there. 

The  epileptic  equivalent  sometimes  consists  of  an  attack  of 
mental  confusion,  like  a dream,  preceded  by  whispers  and  per- 
])lexity,  and  followed  by  sleep.  Such  a case  has  been  published 
by  Norman  Henry  {Journal  of  Nervous  and  Mental  Disease,  1899). 
In  tliis  case  pure  epileptic  attacks  were  absent 


EPILEPTIC  INSANITY 


517 


Sometimes  we  have  instances  of  crime  followed  by  prolonged 
mental  confusion. 

Observation  V. — M.  C.  was  arrested  on  April  2,  1900,  in  Torre 
Annunziata  because  he  made  his  way  into  the  barracks  of  the  Municipal 
Guards  and  insulted  them  without  reason.  He  was  sent  to  the  asylum. 
He  remembered  nothing  of  what  had  happened.  His  father  suffered 
from  haemoptysis  ; his  mother  was  of  a violent  and  aggressive  character. 
The  patient  suffered  from  convulsions  in  infancy.  He  has  been  arrested 
on  various  occasions  for  theft,  rioting,  and  breaches  of  the  peace.  He 
recollects  and  even  boasts  of  some  of  these  crimes,  whilst  he  asserts  his 
innocence  of  others.  He  states  that  he  has  been  tried  several  times  for 
pocket-picking,  of  which  he  was  not  guilty.  He  accuses  the  police  of 
falsehood,  and  therefore  hates  them  cordially. 

He  was  readmitted  to  the  asylum  on  December  25,  1900.  He  was 
dazed,  responded  slowly  to  questions,  not  comprehending  them,  and 
giving  inappropriate  answers.  He  told  his  name.  On  the  28th  he  was 
less  confused  ; he  made  adequate  replies  to  very  simple  questions.  He 
remembered  that  he  had  been  in  prison,  he  recognised  that  he  was  in 
the  asylum  in  which  he  had  been  previously  confined,  but  did  not  re- 
member why  he  was  brought  there.  He  said  that  it  was  possible  he 
had  committed  a theft  or  a murder,  but  remembered  nothing.  From 
December  29  to  31  he  regained  consciousness,  and  also  remembered  the 
crime  he  had  committed.  (He  had  killed  his  aunt,  a hunchback.)  He 
was  in  good  humour,  and  recounted  his  robberies  with  complacency. 

There  may  be  somnambulic  accessions,  during  which  actions 
are  performed  having  all  the  appearance  of  rationality  and  free- 
will {vide  Part  II.  of  this  volume). 

Criminal  acts  are  sometimes  committed  with  a certain  appear- 
ance of  free-will.  Here  are  some  examples  : 

A lady  is  out  walking  ; at  a certain  place  she  enters  a shop, 
murmurs  some  meaningless  words,  and  makes  an  attempt  to  steal 
some  objects  made  of  tortoise-shell.  Surprised,  she  sees  her  mistake, 
but  is  unable  to  explain  why  she  is  in  the  shop  and  in  possession 
of  objects  she  had  no  wish  to  buy. 

A young  lover,  not  being  able  to  obtain  the  consent  of  the  lady 
he  loves,  one  evening  conceals  himself  on  a road  along  which  she 
has  to  pass.  On  seeing  her  he  falls  upon  her,  strikes  her  repeatedly, 
embraces  her,  ejaculates,  and  falls  asleep  on  her  corpse  (Virgilio). 

Ottolenghi  and  others  have  published  interesting  cases. 

A young  man  of  twenty-three  years,  who  had  not  previously 
suffered  from  convulsions,  one  night  murdered  several  members  of 
his  family.  In  the  morning  he  found  himself  lying  in  bed  between 
two  corpses  ; he  knew  nothing,  recollected  nothing ; only  one 
terror-stricken  child,  spared  from  the  carnage,  was  able  to  recount 
what  she  had  seen  the  preceding  night  (Tschisch,  Journal  of  Mental 
Pathology,  1903). 

In  some  cases,  such  as  that  observed  by  Bechterew,  the  acces- 
sion consists  in  the  loss  of  memory  for  a period  of  time — e.g.,  twenty- 
four  hours  ; from  this  state  the  patient  suddenly  passes  into  a state 


5i8 


PSYCHIATRY 


of  full  consciousness  (‘  Periodische  Anfdlle  retroactiver  Amnesic, 
Ohosrenije  Psichiatrii,  1900). 

These  cases  are  at  bottom  only  protracted  lapses.  A very 
simple  case  is  as  follows  : A young  man,  in  his  twenty-first  year, 
has  come  to  consult  me.  While  telling  me  of  his  trouble,  he  breaks 
off,  turns  pale,  mumbles  and  mutters  unintelligible  words  ; with 
his  hands  he  performs  inconsequent  movements,  like  a blind  man 
seeking  for  something  in  his  clothes.  After  less  than  a minute  he 
comes  to  himself  again,  passes  his  hand  over  his  forehead,  and  takes 
up  the  thread  of  his  discourse. 

In  similar  states  epileptics  may  perform  acts  of  indecent  expo- 
sure. There  is  the  case  of  the  judge  who,  whilst  performing  his 
high  function,  rose  and  urinated  in  the  presence  of  the  public,  and 
on  being  reproved  by  his  colleagues  remembered  nothing  of  it 
(Legrand  de  Saulle)  ; the  honest  man  who  unconsciously  mastur- 
bated in  the  most  frequented  thoroughfares  (Morselli)  ; and  the 
young  fiance  who,  on  his  marriage  day,  approached  his  bride,  and 
before  all  the  guests  attempted  to  masturbate,  without  afterwards 
having  any  recollection  of  it  (Lombroso). 

Finally,  the  epileptic  equivalent  sometimes  assumes  the  form 
of  paroxysmal  tachycardia,  with  difficulty  of  breathing,  anxiety, 
sometimes  loss  of  consciousness,  and  other  psychic  disturbances 
(cases  of  Talamon,  Lecorche,  Pitres,  Venturi,  and  especially  those 
of  Bellisari — Riforma  Mcdica,  1890). 

There  may  be  obsessive  ideas  of  theft  or  of  homicide,  often 
preceded  by  headache.  The  following  is  an  example  : 

Observation  VI. — D.  G.,  unmarried,  a mason,  has  never  suffered 
from  convulsions.  He  presents  many  somatic  and  psychic  degenerative 
stigmata — flat  occiput,  receding  forehead,  lop  ears,  Darwin’s  tubercle, 
dental  prognathism,  and  obscene  tattoo-marks.  As  a child  he  used  to 
flee  to  the  open  country  without  knowing  whither  he  was  going,  and 
would  sleep  on  the  ground  or  seek  shelter  in  some  cabin.  Out  of  revenge 
he  attempted  to  set  Are  to  one  of  the  houses  of  correction  in  which  it 
had  been  necessary  to  conflne  him.  Intolerant  of  reproof,  he  very 
nearly  destroyed  the  eyesight  of  a brother  who  rebuked  him  mildly, 
and  he  severely  wounded  a companion  for  an  innocent  jest.  Having 
joined  a ship  as  cabin-boy,  he  passed  a considerable  time  in  various 
prisons  for  being  mixed  up  in  sanguinary  riots  and  for  attempts  at 
escape.  One  day,  finding  himself  at  Genoa  in  the  company  of  marines, 
he  was  suddenly  overwhelmed  by  a terrible  homicidal  idea,  which  he 
immediately  proceeded  to  carry  into  execution.  He  bought  a knife, 
with  the  intention  of  killing  the  first  person  who  should  come  in  his 
way.  In  the  public  gardens  he  met  an  unfortunate  man,  whom  he 
wounded  very  severely.  He  was  delirious  during  the  whole  night  after 
his  arrest.  (From  the  thesis  of  Dr.  A.  Mele,  prepared  in  great  measure 
from  material  in  the  Neapolitan  Clinique.) 

Some  also  regard  as  epileptic  equivalents  those  nocturnal 
terrors  of  infants  depending  upon  dyspnoeic  disturbances  of  re- 
spiration, inasmuch  as  those  disturbances  would  be  the  cause  of 


EPILEPTIC  INSANITY 


519 


dreams  that  give  rise  to  the  nocturnal  terrors  (Graham  Little  and 
J.  Green,  ‘The  Causation  of  Night  Terrors,’  Pediatrics,  vol.  viii., 
1899). 

It  is  very  doubtful  if  we  can  regard  ambulatory  accessions 
with  more  or  less  perfect  preservation  of  consciousness  as  epileptic 
equivalents.  Donath,  who  refers  to  some  such  cases,  does  not 
admit  that  loss  of  consciousness  is  an  essential  feature  of  epilepsy, 
for  such  loss  depends  on  the  degree  of  excitement  of  the  cerebral 
cortex.  According  to  him,  the  essential  feature  of  epilepsy  con- 
sists in  a morbid  excitation  of  the  cortex,  which  manifests  itself 
instantaneously,  returns  periodically,  runs  a typical  course,  and 
disappears  rapidly  {Arch,  fiir  Psych,  u.  Ncrvenkr.,  Bd.  xvii.). 

The  patients  can  sometimes  give  a reason  for  their  actions 
during  the  ambulatory  accession,  but  after  the  accession  there  is 
complete  loss  of  memory  of  the  occurrence  (case  of  McCarthy — 
‘ Epileptic  Ambulatory  Automatism,’  Journal  of  Nervous  and 
Mental  Disease,  1900). 

Sometimes  we  have  an  alternation  of  normal,  or  comparatively 
normal,  states  of  consciousness  with  states  of  confusion,  varying  in 
duration.  Kdppen’s  cases  of  this  kind  are  important,  as  they 
demonstrate  the  change  of  behaviour  that  an  epileptic  may  show 
on  different  days  whilst  undergoing  a medico-legal  examination 
{Charite-Annalen,  1889). 

In  some  cases  the  epileptic  remembers,  and  can  give  even  a 
detailed  account  of,  an  occurrence  immediately  after  it  has  hap- 
pened, yet,  a short  time  afterwards,  he  has  no  further  recollection 
of  it. 

In  a very  interesting  case  of  wife  murder,  committed  in  a small 
village  in  the  province  of  Aquila,  and  brought  up  before  the  local 
court  of  assize,  the  prisoner,  an  epileptic,  who  committed  the 
murder  with  blows  from  an  axe  and  then  remained  quietly  in  the 
house,  gave  an  account  of  the  occurrence  to  the  carabineers  who 
arrested  him,  whilst  he  had  still  under  his  impassive  eyes  the  dead 
body  of  his  wife,  and  even  sought  to  justify  the  murder.  Some 
time  later,  before  the  presiding  magistrate,  who  in  his  turn  hastened 
to  examine  him,  he  was  unable  to  teU  anything,  and  showed  surprise 
at  the  crime  imputed  to  him. 

In  my  opinion  both  in  the  epileptic  equivalents  and  in  the  post- 
epileptic period,  when  the  patient  remembers  for  some  time  after 
the  epileptic  accession  all  that  he  has  done,  and  afterwards  forgets 
it  entirely,  we  have  a condition  resembling  the  state  of  double 
consciousness,  during  which  time  the  subjects  do  not  lose  relations 
with  the  external  world  and  with  the  past,  yet  lose  the  memory 
of  that  period  completely  when  the  state  of  normal  consciousness 
is  re-established.  There  may  also  be  truth  in  the  assertion  of 
Salgo,  who  compares  recollection  after  the  epileptic  attack  to  the 
same  phenomenon  after  dreams  (‘  Die  Bewussteinstand  in  epilep- 


520 


PSYCHIATRY 


ischen  Anfalle,’’  Allgemein  Zeitschr.  filr  Psych.,  Bd.  Ivi.).  It  is 
clear,  however,  that  we  cannot  always  speak  of  complete  amnesia 
and  of  unconsciousness,  for  we  meet  with  facts  that  disprove  such 
a statement.  Not  only  is  amnesia  wanting  in  some  cases,  as  that 
I have  referred  to,  and  as  Tamburini  was  the  first  to  prove,  but 
in  some  cases  we  have  undoubtedly  to  deal  with  true  duplication 
of  the  consciousness. 

I believe  there  is  a good  deal  of  truth  in  what  Thomson  says — 
viz.,  that  the  constant  and  distinguishing  feature  of  epilepsy  is 
the  instantaneousness  of  the  attacks,  and  not  the  loss  of  conscious- 
ness, which  may  be  obscured  in  different  degrees,  without,  however, 
being  completely  abolished  {Knickerbocker  Press,  1900). 

It  is  interesting  also  to  note  that  memory  is  often  later  in  being 
reinstated  than  the  perceptive  capacity,  so  that  a man  in  this  state 
may  recognise  persons  and  objects,  and  even  express  perceptive 
judgments,  yet  afterwards,  when  the  personality  is  re-established, 
remember  nothing  of  such  perceptions  and  judgments. 

These  facts  are  especially  important  from  the  medico-legal 
point  of  view,  as  is  also  the  fact  that  the  crime  committed  may  often 
seem  premeditated  and  logically  connected  with  preceding  data. 
The  husband  who  kills  his  wife  with  whom  he  has  had  bitter  dis- 
pute, and  the  young  man  who  assaults  and  violates  his  sweetheart, 
even  wounding  her,  because  of  her  persistent  refusal  to  yield  to 
his  desires,  translate  into  action,  in  the  unconsciousness  of  an 
epileptic  attack,  some  of  the  preformed  psychic  compounds,  glossed 
over  with  that  veneer  which,  even  in  the  epileptic,  gives  an  appear- 
ance of  reason  in  the  adaptation,  derived,  perhaps  even  in  the 
egoistic  sense,  from  the  knowledge  of  the  moral  relations  and  the 
social  laws,  these  putting  in  movement  those  scanty  regulative 
powers  with  which  he  is  furnished.  This  gloss  is  destroyed  by  the 
breath  of  epilepsy,  and  the  preformed  compounds  acquire  all  their 
excito-motor  power  in  the  complex  structure  of  ‘ the  unconscious,’ 
this  imparting  an  appearance  of  logic  to  the  criminal  actions  com- 
mitted in  the  pre-  and  post-epileptic,  as  well  as  the  epileptic  equiva- 
lent, states. 

As  is  apparent,  the  epileptic  equivalent,  also  known  as  masked 
epilepsy,  assumes  the  most  varied  forms,  which,  however,  are  dis- 
tinguished from  one  another  by  certain  features,  even  when  there 
is  no  record  of  epilepsy.  Those  features  are  the  instantaneousness, 
the  brevity,  the  recurrence,  the  disturbance  of  the  consciousness, 
the  amnesia  (very  frequent  if  not  constant). 

It  is  certain  that,  when  such  syndromes  arc  manifested  in  epileptic 
individuals,  no  difficulty  in  diagnosis  is  met  with.  The  difficulties 
arise  when  the  person  to  whom  the  supposed  epileptic  equivalent 
is  attributed,  is  said  never  to  have  suffered  from  epilepsy.  In 
such  cases  it  is  necessary  in  our  examination  to  direct  our  attention 
to  three  facts  that  often  escape  observation  : (i)  Epilepsy,  crimi- 


EPILEPTIC  INSANITY 


521 


nality,  or  alcoholism  in  the  family  ; (2)  well-marked  epileptic  char- 
acter ; (3)  eclampsia  in  infancy,  which  is  nothing  else  than  epilepsy 
of  infancy,  with  which  the  late  epilepsies  are  very  frequently  allied, 
although  other  causes  are  invoked  to  explain  them — alcoholism, 
syphilis,  some  doubtful  injury,  or  an  intestinal  intoxication. 

Protracted  Confusional  or  Crepuscular  States. — A condition  of 
confusion  sometimes  persists  for  many  weeks,  and  even  for  several 
months,  after  convulsive  accessions,  even,  in  rare  cases,  when  there 
has  been  no  outward  evidence  of  such  an  attack. 

In  these  cases  the  consciousness  is  more  or  less  profoundly 
disturbed  ; the  perceptions  are  slow  and  incomplete,  the  judgments 
erroneous  or  falsified  by  illusions  ; even  hallucinations  arise  from 
time  to  time  ; thought  is  torpid  and  slow,  association  less  active 
and  erroneous,  the  delirious  ideas  now  fleeting,  now  persistent,  as 
in  hallucinatory  paranoia.  In  the  confusion  there  is  sometimes 
outlined  a delirium,  with  a tendency  to  become  systematized. 
The  delirium  is  of  diverse  content — grandiose,  proud,  mystic,  or 
persecutory,  in  which  case  it  assumes  rather  the  character  of  that 
presented  by  the  persecuted  persecutor.  There  is  in  all  cases 
mental  dissociation  ; there  are  lapses  of  memory  and  a state  of 
confused  memory,  in  which  there  is  a mixing  up  of  things  real  with 
things  imaginary  ; alternations  of  loquacity  and  stuporous  arrest, 
of  profound  confusion  and  of  almost  normal  lucidity,  great  affective 
excitability  or  dreaming  states  ; the  patients  are  self-absorbed, 
and  react  only  to  very  intense  stimuli.  There  are  soliloquies, 
verbigeration,  excited  language,  paraphrasias  and  dyslogias ; later 
on,  a confused,  lacunar  memory  of  all  the  long  period,  with  occasional 
remissions.  Complete  restoration  is  effected  slowly.  Sometimes 
these  states  are  not  followed  by  recovery,  but  leave  behind  pheno- 
mena of  mental  decadence,  whilst  the  epileptic  character  is  almost 
always  left  more  accentuated. 

The  different  psychopathic  pictures  I have  sought  to  reproduce 
here  on  general  lines  are  accompanied  by  anthropological  anomalies 
and  functional  disorders.  On  these  points  congenital  delinquency 
and  epilepsy  almost  perfectly  coincide.  The  same  anthropological 
stigmata  are  found  in  criminals  as  in  epileptics,  save  that  plagio- 
cephaly,  plagioprosopia,  oblique  cranium  (Lasegue),  and  macro- 
cephaly  are  more  frequent  in  epilepsy.  Very  marked  plagiocephaly 
is  often  related  in  its  genesis  with  meningo-encephalitic  processes 
in  infancy,  just  as  macrocephaly  is  related  with  rickets  and  hydro- 
cephaly, which  frequently  produce  epilepsy.  The  broad  and  high 
forehead,  the  large  nose,  the  long  and  heavy  face,  and  the  thick 
lips,  lend  to  the  epileptic  a physiognomy  quite  recognisable. 

Amongst  the  functional  disturbances  are  to  be  noted  : spastic 
hemiplegia,  diplegia,  atrophy  of  the  optic  papilla,  strabismus, 


522 


PSYCHIATRY 


bilateral  homonymous  hemianopsia,  all  of  which  give  evidence 
of  the  existence  of  old  processes  that  have  occurred  in  the  cerebral 
mass,  and  are  always,  or  almost  always,  accompanied  by  epilepsy. 
There  are  frequently  noted  the  same  anomalies  of  sensibility  men- 
tioned in  connection  with  born  criminals. 

Special  mention  is  made  of  a particular  kind  of  expression  by 
no  means  confined  to  the  epileptic  ; it  is  the  so-called  metallic  look, 
the  ‘ metallic  gloss  ’ of  Tschisch  (‘  Larval  Epilepsy,’  The  Journal 
of  Mental  Pathology,  1903).  According  to  this  author,  it  is  a charac- 
teristic sign  of  essential  epilepsy,  cannot  be  confounded  with  the 
clear  look  of  mania  and  of  hysteria,  and  is  due  to  a particular 
intoxication.  There  is  no  doubt  the  physiognomy  of  the  epileptic 
is  characteristic  when  the  forementioned  anthropological  signs 
are  present,  particularly  when  accompanied  by  the  furtive,  sinister, 
and  uncertain  look — a very  valuable  sign. 

Disturbances  of  speech  are  frequent  (Ross,  Kahlbaum,  Clark) 
and  very  varied.  The  most  frequent  is  a form  of  explosive,  spas- 
modic bradylalia,  with  a heightened  pitch,  and,  as  a rule,  a mono- 
tonous tone  of  voice.  When  the  ^disease  is  of  long  standing,  verbal 
amnesia  is  also  frequent.  In  the  post-epileptic  phase  we  may 
have  word  - deafness  or  word  - blindness,  or  echolalia.  These 
dysphasias  have  the  same  signification  as  the  post-epileptic 
paralyses,  whose  disappearance,  like  that  of  the  dysphasias,  does 
not  invariably  go  hand-in-hand  with  the  reintegration  of  the  con- 
sciousness. 

I have  often  found  stammering  (spasmodic  laloneurosis)  in  asso- 
ciation with  epilepsy.  Even  in  the  absence  of  convulsions  one  often 
finds  in  stammerers  a character  closely  resembling  the  epileptic. 

Alessi  and  Fieri,  of  the  institute  of  Professor  Sadun,  found 
rapid  and  wide  variations  in  the  elimination  of  phosphoric  acid, 
thus  proving  to  their  minds  that  in  the  epileptic  there  is  an  oscil- 
latory state  of  the  functional  capacity  of  the  chemical  groups  of 
the  various  tissues  of  the  organism,  corresponding  to  the  morpho- 
logical and  psychic  asymmetries. 

Whether  myoclonus  is  to  be  considered  as  analogous  to  epilepsy, 
being  dependent  upon  the  same  lesions  as  are  the  cause  of  epilepsy, 
is  a matter  that  requires  many  well-conducted  investigations  for 
its  proof,  notwithstanding  the  fact  that  the  cases  of  Seppilli  and  of 
B.  Verga  and  P.  Gonzales  {Annali  di  Nevrologia,  xvii.)  lend  support 
to  such  a view. 

JEtiology. — This  is  the  same  for  epileptic  insanity  as  for  the 
convulsive  form  of  epilepsy. 

Heredity  plays  the  greatest  part,  and  in  most  instances  is  direct 
and  similar.  The  epileptic  generates  the  epileptic.  Alcoholism 
is  the  next  most  potent  factor.  When  alcoholism  does  not  produce 
epilepsy  in  the  drunken  father,  it  induces  it  in  the  offspring  ; and 


EPILEPTIC  INSANITY 


523 


when  alcoholism  cannot  be  proved  in  the  parent,  it  can  be  traced 
to  the  grandparents  or  the  great-grandparents  (Robinovitch).  In 
140  cases  of  epilepsy  examined  by  Robinovitch,  the  direct  ante- 
cedents in  ninety  cases  (64  per  cent.)  had  been  alcoholists.  The 
old  observations  of  Nothnagel,  Westphal,  Fiirstner,  and  Krafft-Ebing 
have  been  confirmed  by  Christian,  Francotte,  Ottolenghi,  Seppilli, 
Lui,  Pianetta,  Bratz,  Salgo,  and  others. 

Now  that  the  doctrine  of  the  toxic  origin  of  epilepsy  has  come 
to  the  front,  in  consequence  of  the  labours  of  Voisin,  Haig,  Teeter, 
Weber,  Agostini,  Marinesco,  Ceni,  Ferranini,  and  others,  it  finds 
almost  no  opposition  to-day,  and,  indeed,  claims  most  of  the  scientific 
convictions  in  this  regard.  When,  however,  we  attempt  to  prove 
by  actual  facts  the  hypotheses  formulated  and  accepted  with  such 
freedom,  we  find  them  to  be  upheld  more  by  the  subjective  consent 
of  the  majority  of  authors  than  by  really  incontestable  proofs. 

First  of  all,  it  is  well  to  establish*  the  fact  that  it  is  not  a question 
of  specific  intoxication,  but  of  a great  variety  of  intoxications 
giving  identical  results.  Indeed,  while  Voisin,  Herter,  Massalongo, 
Christian,  and  Agostini  hold  the  intoxication  to  be  produced  by  toxin 
generated  in  the  gastro-intestinal  canal,  Haig  maintains  an  accumu- 
lation of  uric  acid,  and  Krainsky  of  carbonic  acid,  in  the  blood  ; 
others  consider  it  due  to  the  toxins  produced  by  infective  disease 
suffered  by  the  mother  during  pregnancy  ; others,  again,  attribute 
it  to  alcohol  (Bratz  and  Salgo,  Luise  Robinovitch,  Fere). 

Some  observers,  such  as  Voisin  and  Bra,  would  like  to  connect 
epilepsy  with  the  presence  of  micro-organisms  (streptococci)  in 
the  blood,  a condition  which  Besta  was  unable  to  confirm. 

This  is  a question  of  considerable  interest,  for  all  the  observations 
thus  far  recorded  go  to  prove  that,  even  granting  the  toxic  origin 
of  epilepsy,  the  intoxication  would  be  produced  by  normal  sub- 
stances derived  from  the  tissue  metabolism  (uric  acid),  or  by 
those  generated  as  the  result  of  altered  interchange  in  the  tissues, 
or  by  toxins  and  ptomaines  in  the  intestine,  or,  lastly,  by  exogenous 
toxic  substances  (alcohol,  absinthe).  When,  on  the  other  hand, 
we  consider  the  identical  forms  of  epilepsy,  provoked,  in  the  first 
place,  by  a splinter  of  bone  driven  into  the  cortex,  and  in  the  second 
by  exciting  with  electricity  the  cerebral  cortex,  preferably  certain 
zones,  the  toxic  origin  of  epilepsy  must  be  reduced  to  its  true  value. 
In  my  opinion  epilepsy  depends  upon  the  inherited  structure  of 
the  brain,  or  upon  the  alterations  therein  induced  by  the  action 
of  some  poisons  that  have  long  been  in  operation,  e.g.,  alcohol  or 
syphilis,  and  by  coarser  lesions.  It  is  certain  that  only  in  the  long 
run  (after  many  years  of  abuse)  does  alcohol  give  rise  to  epilepsy, 
and  only  after  months  or  years  does  a trauma  give  it — that  is  to 
say,  when  they  are  followed  by  histological  alterations  that  break 
the  functional  rhythm  of  the  various  parts  of  the  brain,  which  we 
hold  to  be  the  basis  for  a regular  flow  of  the  nerve-waves. 


524 


PSYCHIATRY 


On  the  other  hand,  examination  of  the  urine  in  epileptics  gives 
no  certain  result. 

According  to  the  researches  of  Deny  and  Chouppe  {Comptes 
Rendus  de  la  Societe  de  Biologic,  1899),  the  urine  of  thirteen  epileptics 
proved  no  more  toxic  than  the  urine  of  normal  individuals.  The 
enthusiasm  of  Fere,  who  found  the  pre-paroxysmal  urine  thirteen 
times  more  toxic  than  the  post-paroxysmal,  was  extinguished  by 
the  researches  of  Chevalier  of  Lavaur,  who  found  diminution  of  the 
urotoxic  power  in  the  state  of  epileptic  excitement.  The  conclu- 
sions of  Brugia,  Tamburini,  and  Vassale  are  unreliable.  Whilst 
Mirto  and  Agostini  admit  a true  increase  of  the  urinary  toxicity  in 
epileptics,  and  especially  in  the  period  preceding  the  attack,  Mari- 
nesco  and  Serieux,  and  Mairet  and  Vires  found  a constant  hypo- 
toxicity  after  the  attacks  and  in  the  intervals  between  them.  Again, 
the  experiments  of  A.  Keester,  carried  out  on  rabbits,  dogs,  and 
monkeys,  did  not  confirm  the  toxicity  of  the  blood  of  epileptics 
before  and  after  the  attacks  {Journal  of  Nervous  and  Mental  Disease, 

1899) .  The  labours  of  Didi  and  Stenuit  {La  polyurie  et  V excretion 
de  luree  dans  Vepilepsie,  1899),  who  almost  always  found  the  per- 
centage of  urinary  substances  in  epilepsy  under  the  normal,  allow 
of  no  sure  conclusion.  The  diminished  alkalinity  of  the  blood 
found  by  Lui  during  and  immediately  after  the  attack,  is  of  no 
signification  in  the  pathogenesis  of  epilepsy.  No  doubt,  were  we 
to  find  a constant  diminution  in  the  quantity  of  uric  acid  in  the 
urine  in  the  twenty-four  hours  coinciding  with  the  manifestation 
of  the  accessions,  as  Caro  found  in  one  case  {Deut.  Medicin.  Wochens., 

1900) ,  the  doctrine  of  Haig  would  receive  considerable  support  ; 
observations  of  a like  kind,  however,  are  scarce  and  even  contra- 
dictory. 

The  variety  of  results  cannot  even  be  attributed  to  the  methods 
followed,  however  different  they  may  be,  for  the  differences  pre- 
sented are  too  great — so  much  so  that  sometimes  they  seem  wholly 
opposed  to  one  another. 

The  researches  of  Pellegrini  {Riforma  Medica,  anno  xvii.)  would 
appear  to  be  of  greater  value.  This  author  has  found  the  cerebro- 
spinal fluid  of  the  epileptic  to  be  very  toxic  immediately  after  the 
accession,  and  less  toxic  some  time  afterwards.  Those  observations, 
however,  being  few  and  isolated,  cannot  yet  contribute  to  the  genesis 
of  epilepsy. 

The  toxic  doctrine  of  epilepsy  accordingly  represents  an  attempt 
at  interpretation,  and  perhaps  the  endogenous  intoxications  repre- 
sent only  a coefficient  in  the  aetiology  of  the  great  neurosis. 

The  investigations  carried  out  on  the  blood  of  epileptics  possess 
no  greater  value  ; it  is  sufficient  to  mention  the  results  of  the 
researches  of  D’  Abundo  and  of  Ceni,  results  completely  opposed  to 
one  another,  in  order  to  realize  the  extent  of  the  dubiety  surrounding 
this  subject,  dubiety  not  lessened  by  the  researches  of  Voisin  and 


EPILEPTIC  INSANITY 


525 


Peron,  of  Legrain  and  Guerin,  of  Mairet  and  Vires,  and  of  Herter, 
who  could  educe  no  conclusion  from  his  experiments  (Journal  of 
Nervous  and  Mental  Disease,  1899). 

The  experiments  upon  the  teratogenic  power  of  the  blood  of 
epileptics  would  appear  to  be  of  more  value.  The  numerous 
researches  of  Ceni,  following  on  general  lines  the  methods  of 
Fere,  have  convinced  him  that  epilepsy  is  due  to  an  alteration  of 
the  tissue  metabolism,  whence  the  formation,  then  the  presence 
in  the  blood,  of  a toxic  substance  that  induces  in  the  embryo 
deviation,  especially  of  the  brain,  from  the  normal  evolution,  and 
irritates  the  cerebral  cells  of  the  developed  brain.  The  epileptic’s 
accessions  would  be  caused  by  this  irritation.  According  to  Ceni 
(Rivista  Sperimentale  di  Ereniatria,  1897 , 1899,  1900),  the  intoxi- 
cation is  not  casual  and  intermittent,  but  general,  permanent,  and 
constant,  apart  from  the  accessional  manifestations.  This  patho- 
logical conception  should  lead  Ceni  to  seek  for  a rational  cure 
founded  on  the  doctrine  of  serum-therapy.  This  would  have  a 
logical  basis  were  intoxication  in  epilepsy  shown  to  be  a constant 
factor. 

There  can  be  no  doubt  that  up  till  now  there  is  no  fact  to  warrant 
such  a hypothesis  being  held  as  proved. 

Though  intoxication  may  be  held  to  be  the  direct  cause  of 
the  epileptic  accession,  whatever  its  form,  psychopathic  heredity, 
direct  or  collateral,  is  the  true  cause  of  epilepsy  ; above  all,  epilepsy 
in  the  family,  alcoholism,  criminality,  paranoia,  and  cerebral  haemor- 
rhage. Acute  sensory  insanity,  mania,  and  especially  melancholia, 
are  of  rather  less  importance. 

All  the  organic  diseases  of  the  brain  may  give  rise  to  epilepsy, 
but  more  particularly  destructive  foci,  cysts,  hydatids,  and  tumours. 

Traumata,  even  when  they  do  not  produce  lesions  of  the  bone 
or  meningeal  haemorrhages,  may  give  rise,  after  a longer  or  shorter 
time,  sometimes  after  years,  to  epilepsy.  Without  doubt  an 
injury,  even  when  it  does  not  produce  haemorrhages  at  the  seat  of 
action  or  in  remote  (opposite)  sites,  determines  alterations  in  the 
minute  structure  of  the  brain,  which  must  be  regarded  as  a direct 
and  immediate  cause  of  epilepsy. 

It  is  thus  that  alcohol  and  syphilis  act.  It  has  been  stated  that 
the  majority  of  epilepsies  developing  in  maturity  are  of  syphilitic 
origin.  I maintain  that  the  syphilitic  genesis  of  epilepsy  is  much 
exaggerated.  A considerable  number  of  late  epileptics  are  burdened 
by  severe  psychopathic  heredity,  and  have  suffered  from  eclampsia 
in  infancy.  Now,  it  is  a simple  matter  for  all  who  have  an  abun- 
dance of  clinical  material  at  their  disposal  to  convince  themselves 
that  the  epilepsy  of  maturity  in  individuals  who  have  suffered 
eclampsia  in  infancy  is  only  the  continuation  of  the  latter,  which 
is  in  reality  infantile  epilepsy. 

Frequently  associated  with  epilepsy  we  find  rachitis  (rachitis 


PSYCHIATRY 


526 

of  the  head),  and,  according  to  some,  even  thymic  asthma,  which 
is  related  to  the  lymphatic  constitution  (Ohlmacher)  ; these  may 
be  considered  as  causes  of  epilepsy. 

The  pathological  anatomy  of  epilepsy  is  still  very  obscure.  With 
the  exception  of  the  teratological  conditions  met  with  in  the  cere- 
brum and  cerebellum  of  epileptics  (asymmetry,  greater  simplicity 
of  the  sulci,  continuation  of  some  sulci  with  others  through  absence 
of  intervening  folds),  we  can  express  a legitimate  doubt  with  regard 
to  all  the  other  anatomo-pathological  features  as  to  whether  they 
are  not  rather  the  effect  of  the  epilepsy  than  the  process  from  which 
the  epilepsy  emanates.  There  is  one  group  of  epilepsies  which  is 
excluded  from  the  preceding  synthetic  consideration— viz.,  that 
group  whose  genesis  is  certainly  connected  with  the  presence  of 
destructive  foci  or  of  other  processes  in  the  brain  (tumours,  foreign 
bodies)  ; but  even  in  these  cases  we  may  ask  if  these  states  are  the 
immediate  cause  of  the  epilepsy,  or  if  they  represent  a remote 
and  indirect  cause  of  the  mechanism  whence  epilepsy  is  produced 
(vide  ante). 

The  teratological  anomalies  above  mentioned  are  certainly 
significant  of  incomplete  cerebral  development,  and  are  found  in 
delinquents  and  imbeciles  as  well  as  in  epileptics.  Among  investi- 
gations in  proof  thereof  we  may  mention  those  of  Wildermuth, 
Dercum,  Benedikt,  Ferrier,  Lemoine,  Mingazzini,  Tenchini,  Otto- 
lenghi,  and  Roncoroni.  It  is  not  to  be  thought  that  these  anomalies 
are  not  found  in  the  brains  of  normal  individuals,  but  their  pro- 
portionate frequency  in  epileptics  is  certainly  very  significant. 

The  meninges  in  general  are  either  normal,  as  when  the  epilepsy 
is  not  of  very  long  standing,  or  more  or  less  opaque,  thickened 
and  sometim.es  adherent  to  the  cortex.  In  some  rare  cases,  such  as 
that  referred  to  by  Usuelli  and  Venanzio,  we  find  more  serious 
meningeal  and  even  osseous  alterations  (bony  plates  situated 
alongside  the  longitudinal  sinus,  covered  with  membrane  and 
adapted  to  the  cerebral  convexity). 

To  the  naked  eye  the  cerebral  substance  often  presents  a normal 
appearance  (Gowers,  Fere,  and  many  others).  As  mentioned  a 
short  time  ago,  apoplectic  cysts,  focal  or  diffuse  sclerosis,  en- 
cephalitis, porencephaly,  and  cysticercus  * are  comparatively  fre- 
quent ; but,  as  I have  said,  these  lesions  do  not  represent  the  imme- 
diate anatomical  substratum  of  epilepsy,  and  they  are  found  in 
the  most  diverse  parts  of  the  brain,  even  when  the  epileptic  con- 
vulsion at  the  commencement  partakes  of  the  Jacksonian  character. 
The  old  belief  that  these  lesions  should  be  found  in  the  vicinity 

* Cerebral  cysticercus  is  rare  in  comparison  with  the  frequency  of  epilepsy. 
It  gives  rise  not  only  to  all  forms  of  epilepsy,  but  also  to  epileptic  insanity 
with  deliria,  hallucinations,  impulses,  and  furor  (Lombroso,  Martinetti, 
Tirelli,  and  Lui). 


EPILEPTIC  INSANITY 


527 


of  the  Rolandic  zone  has  been  refuted  by  facts  (observations  of 
Gonzales  and  Verga,  of  Seppilli,  Ventra,  and  several  observations 
of  my  own).  The  cerebellum,  the  corpus  striatum,  and  the 
medulla  oblongata  are  no  rare  sites  for  such  processes  in  epileptics. 

After  the  researches  of  Meynert,  great  significance  was  attached 
to  the  cornu  ammonis  (Meynert,  Sommer,  Beliakoff,  Fischer, 
Gowers).  A more  accurate  investigation  in  this  connection  has 
been  made  by  Borosdin,  Rosenstein,  and  Ljubimow  (‘  Ueher  Ver- 
anderungen  des  Ammonshorns-hei  Epilepsie,''  Ohosrenije  PsichL 
atrii,  1900),  who  in  nine  cases  of  epilepsy  have  found  notable  lesions 
in  the  cornu  ammonis — degeneration  of  the  cells,  disappearance  or 
shortening  of  the  protoplasmic  processes,  atrophy  of  the  elements 
of  association,  proliferation  of  the  neuroglial  elements,  degenera- 
tion of  the  vessels,  infiltration  of  the  perivascular  spaces  with  leuco- 
cytes. These  alterations,  however,  have  not  the  value  of  a specific 
lesion  as  regards  either  nature  or  site,  because  they  are  found 
throughout  the  cerebral  cortex,  and  also  in  other  diseases,  so  that 
they  must  be  regarded  rather  as  an  effect  of  the  repetition  of  the 
convulsive  accessions. 

In  the  cases  where  the  brain  appears  normal  the  histological 
alterations  are  reduced  to  minute  alterations  of  the  cerebral  cells, 
especially  to  the  increase  of  the  neuroglia,  and  to  nutritive  altera- 
tions in  the  vessel-walls. 

Chaslin  found  in  epileptics  a variety  of  cerebral  sclerosis  which 
he  considered  non-inflammatory,  but  inherited,  primary,  and 
constitutional.  Amongst  the  more  or  less  altered  nerve-cells  are 
found  neuroglial  fibrils,  which  in  some  parts  of  the  brain  are 
increased  to  such  an  extent  as  to  form  bundles  of  neuroglia,  with  a 
large  number  of  neuroglial  cells.  In  these  fields  the  capillaries  are 
scarcer,  and  some  even  obliterated.  Such  a finding  has  been 
generally  confirmed  (Fere,  Kinsburg,  Blocq,  and  Marinesco). 

Alterations  in  the  cells  and  vessels,  as  well  as  increase  of  the 
glia,  were  found  by  Marinesco  in  rabbits  in  which  he  had  pro- 
duced a form  of  experimental  epilepsy  by  means  of  injections  of 
an  extract  of  absinthe  (‘  Contribution  d FHude  de  V anatomic  patho- 
logique  et  de  la  pathogenic  de  repilepsie  dite  essentielleP  Medecine 
Roumaine,  1899).  Nevertheless,  he  does  not  believe  that  he  is 
warranted  in  concluding  that  these  alterations  represent  the  genesis 
of  the  convulsive  accession. 

Degeneration  of  the  myeline  of  the  fibres  appears  to  have  been 
observed  by  Marinesco  and  Serieux,  employing  Marchi’s  method. 

Olmer,  Marinesco,  and  Serieux,  using  the  most  recent  methods 
of  staining,  have  found  very  marked  chromatolysis  of  the  pyra- 
midal cells,  displacement  of  the  nucleus  towards  the  periphery,  and 
degeneration  of  the  nucleoli.  Some  believed  they  had  found  hyper- 
trophy of  some  pyramidal  cells  (Coined,  Marinesco)  ; Bleuler  has 
found  hypertrophy  of  the  layer  of  neuroglia  under  the  pia  mater 


528 


PSYCHIATRY 


Alzheimer  has  found  alteration  of  the  tangential  fibres.  Even 
these  alterations,  however,  are  not  specific,  being  found  to  an 
equal  extent  in  a great  variety  of  diseases. 

In  one  case  in  which  death  occurred  during  the  status  epilep- 
ticus  and  in  another  where  death  occurred  during  a severe  and 
prolonged  convulsive  attack,  I formd  at  the  autopsy  a marked 
congestion  of  the  meninges  and  of  the  cerebral  cortex,  extravasa- 
tions of  blood  at  different  points  of  the  brain,  especially  in  the 
gray  substance,  and  cerebral  oedema. 

In  analogous  cases  cellular  lesions  have  been  met  with,  par- 
ticularly in  the  vicinity  of  the  vessels,  and  these  also  presented 
recent  alterations. 

In  some  cases  the  thymus  has  been  found  much  enlarged. 

Bacteriological  researches  have  brought  to  light  the  presence 
of  the  bacillus  of  diphtheria,  the  staphylococcus,  and  the  Bacillus 
mucosus  capsulatus  (Friedlander). 

After  this  brief  review  I express  the  conviction,  not  the  mere 
suspicion  expressed  by  Marinesco,  that  the  lesions  found  in  the 
brains  of  epileptics  are  the  effects  of  the  repetition  of  the  acces- 
sions. 

Diagnosis. — The  diagnosis  of  the  epileptic  psychosis  is  founded 
principally  upon  the  definite  history  of  epilepsy.  The  historical 
inquiry  must  be  made  to  cover  the  whole  life,  not  omitting  infancy 
(eclampsia),  and  must  also  embrace  the  family  history  (epileptic 
parents  or  relatives). 

In  the  absence  of  historical  data,  the  best  criteria  are  : 

1.  The  suddenness  with  which  the  psychic  disturbance  arises, 
no  matter  what  its  form. 

2.  The  profound  disturbance  of  the  consciousness,  and  the 
phenomena  of  psycho-motor  automatism. 

3.  The  ready  remission  of  the  phenomena,  with  amnesia,  com- 
plete or  incomplete,  of  the  whole  period  of  the  illness. 

4.  The  existence  of  the  marked  anthropological  signs  that  are 
most  frequently  met  with  in  epileptics  (plagiocephaly,  plagio- 
prosopia,  oblique  cranium — so-called  by  Lasegue). 

5.  The  presence  of  residua  of  old  cerebral  diseases  (infantile 
spastic  hemiplegia,  asymmetry  in  the  limbs,  strabismus). 

Admitted  the  possibility  that  the  epileptic  equivalent  may  run 
its  course  without  profound  disturbance  of  the  consciousness 
(although  this  occurs  rarely),  many  forms  of  transitory  insanity 
may  be  considered  as  epileptic  equivalents,  whilst  other  cases  come 
under  other  morbid  states  well  recognised  to-day,  especially  the 
coercive  impulsions,  the  raptus  melancholicus,  and  the  provoked 
transitory  excitement  in  states  of  dementia.  I do  not  share  the 
opinion  of  Venturi  and  Tonnini,  who  distinguished  transitory 
insanity  from  epilepsy  ; on  the  contrary,  there  is  a distinct  resem- 


EPILEPTIC  INSANITY 


529 


blance  between  transitory  insanity  and  the  epileptic  equivalent — ■ 
in  fact,  it  is  impossible  to  draw  a distinction  between  them  (Lom- 
broso,  Tanzi,  Congresso  Freniatrico  Italiano  in  Siena,  1886).  Even 
the  acute  psychosis  from  alcoholic  intoxication  sometimes  runs  its 
course  like  an  epileptic  equivalent.  In  this  case  the  patient’s 
history  helps  us,  even  when  there  is  no  evidence  of  somatic  altera- 
tions produced  by  the  alcohol  (neuritis).  Sometimes  we  have  to 
deal  with  alcoholic  intoxication  in  an  epileptic. 

The  diagnosis  of  a psychic  disturbance  following  upon  an  epileptic 
convulsion  at  the  commencement  of  progressive  paralysis  is  very 
difficult,  the  more  so  because  in  some  cases  progressive  paralysis 
is  initiated  with  epileptiform  accessions  which  can  with  difficulty 
be  distinguished  from  ordinary  epilepsy,  and  may  even  precede 
by  several  months,  or  a year  or  so,  the  appearance  of  phenomena 
more  significant  of  the  great  psychosis.  When  the  intelligence 
is  not  perfectly  regained,  or  an  inequality  of  the  pupils  remains 
for  some  time,  or  when  we  find  the  patellar  reflex  absent,  we  have 
good  reason  to  doubt  the  genuine  character  of  the  epileptic  attack, 
and  to  consider  it  probable  that  we  are  dealing  with  an  initial 
syndrome  of  progressive  paralysis. 

Sometimes  epileptic  insanity  may  be  confounded  with  an 
alcoholic  psychosis,  the  more  readily  because  alcoholists  periodically 
fall  into  excesses,  which  may  give  rise  to  epileptiform  attacks  and 
psychic  disturbances  closely  resembling  the  epileptic  psychosis. 
It  is  well  to  add  that  an  alcoholic  psychosis  sometimes  develops 
in  an  epileptic  constitution,  and  that,  on  the  other  hand,  an  attack 
of  epileptic  psychosis  may  be  brought  on  in  the  long  run  by  the 
degenerating  action  of  alcohol.  In  all  these  cases  the  history  of 
the  patient  does  not  help  us,  and  it  is  often  impossible  to  make  a 
differential  diagnosis  between  epileptic  and  alcoholic  psychosis, 
and  to  distinguish  what  belongs  to  epilepsy  from  what  belongs  to 
alcoholic  intoxication.  On  the  other  hand,  such  a distinction 
serves  no  useful  purpose  when  we  remember  the  relations  between 
epilepsy  and  alcoholism  {vide  ante).  I report  here  a very  recent 
case  bearing  upon  this  question.  A young  man  in  good  circum- 
stances came  up  for  trial  before  the  High  Court  ; he  was  the  son 
and  nephew  of  alcoholists,  and  he  himself  drank  to  excess  ever}^ 
afternoon,  visiting  several  public-houses.  One  evening  he  returned 
home,  drunk  as  usual,  went  into  the  kitchen,  took  something  for 
supper  and  demanded  a bottle  of  wine,  after  drinking  which  he 
stretched  himself  out  on  a mattress  beside  the  fire.  Asked  by  his 
wife  to  go  to  bed,  he  refused,  and  went  to  sleep  on  the  mattress. 
When  four  hours  had  elapsed  he  rose,  went  into  the  bedroom, 
seized  his  wife  by  the  hair  and  pulled  her  on  to  the  floor  ; he  then 
took  up  a double-barrelled  gun,  intending  to  shoot  her.  The  wife 
defended  herself  desperately,  and  managed  to  disarm  him,  after 
which  she  unloaded  the  gun  by  the  breech.  This  done,  she  hastened 

34 


530 


PSYCHIATRY 


towards  her  infants,  who  had  awakened,  and  were  terrified  by  the 
scene  enacted  before  them. 

The  husband  again  took  up  the  gun,  loaded  it  with  a cartridge 
he  found  in  one  of  his  pockets,  and  turning  once  more  towards  his 
wife,  discharged  it  at  her,  almost  at  arm’s  length,  inflicting  injuries 
that  proved  fatal.  This  man,  in  addition  to  habitual  drunkenness, 
had  had,  at  long  intervals,  epileptic  attacks.  There  had  been  no 
serious  dissension  between  himself  and  his  wife.  He  afterwards 
remembered  the  crime,  which  was  the  resultant  of  two  co-ordinating 
forces — epilepsy  and  alcoholism. 

Again,  the  history  of  the  cases  will  be  of  great  help  in  diagnosing 
those  forms  of  periodic  psychosis  that  closely  resemble  one  of  the 
pre-epileptic  syndromes  and  are  related  to  the  menstrual  function 
in  women. 

The  diagnosis  of  the  hysterical  attack  (hysterical  psychosis  and 
the  hysterical  equivalent)  will  be  discussed  more  advantageously 
when  treating  of  hysterical  psychosis. 

Prognosis. — The  prognosis  of  the  epileptic  psychosis  should  be 
reserved,  bearing  in  mind  that  we  are  confronted  with  one  of  the 
gravest  of  diseases.  The  cases  that  give  rise  to  comparatively 
little  anxiety  are  those  in  which  the  convulsions  are  rare  and  the 
epileptic  character  has  not  been  developed  in  its  entirety.  Mild 
forms  that  yield  to  treatment  and  do  not  destroy  the  character 
to  any  marked  degree  are  very  frequent.  Most  serious  and  intract- 
able are  those  cases  in  which  the  convulsions,  more  or  less  intense, 
are  repeated  at  brief  intervals,  and  where  there  already  exists  at 
least  a moral  mental  decadence.  It  is  not  uncommon,  however, 
to  meet  with  epileptic  psychoses  which  are  not  repeated,  even  when 
the  convulsions  follow  one  another  with  a certain  frequency.  The 
epilepsy  of  infancy  which  has  stoutly  resisted  treatment  with 
bromide  is  of  very  grave  prognosis,  especially  so  when  there  are 
present  residua  of  an  infantile  cerebral  affection  (infantile  spastic 
hemiplegia,  optic  atrophy,  microphthalmia,  etc.).  The  epileptic 
psychosis  which  is  recurrent  is  grave  ; the  protracted  form  is  the 
most  threatening  to  the  intelligence. 

Therapy. — To  put  the  epileptic  under  conditions  that  prevent 
him  doing  damage,  when  he  shows  a tendency  thereto,  is  the  first 
duty  of  the  clinician.  This  task  is  entrusted  to  the  asylum  phy- 
sician, and  we  shall  discuss  it  in  the  general  treatment  of  the  mental 
affections.  The  use  of  the  leech  and  blood-letting  have  been 
advised,  on  the  ground  of  the  prevalent  doctrines  of  the  toxic 
genesis  of  epilepsy,  and  practical  experience  has  confirmed  the 
efiicacy  of  depletions  of  blood.  To  empty  and  disinfect  the  intes- 
tines as  promptly  as  possible  with  abundant  lavages,  to  put  the 
patient  upon  milk  diet,  to  withdraw  him  from  as  many  stimuli 


EPILEPTIC  INSANITY 


531 


as  possible,  are  methods  of  treatment  which  will  help  us  to  obtain, 
in  the  shortest  possible  time,  the  reintegration  of  the  personality. 

Alcoholic  liquor  in  any  form  whatsoever  must  be  absolutely 
proscribed.  This  is  of  the  highest  importance. 

If  the  attack  is  prolonged  beyond  the  twenty-four  hours  after 
the  application  of  leeches  or  the  blood-letting,  hypodermic  trans- 
fusion is  recommended.  The  effects  of  this  treatment  are  often 
surprising. 

The  bromide  treatment  has  remained  all  along  the  most 
promising.  All  the  proposed  modifications,  some  of  them  associated 
with  the  names  of  recognised  authorities,  have  resulted  in  almost 
complete  disillusion.  I refer  to  Flechsig’s  method,  which  from  time 
to  time  stirs  up  the  hopes  of  some  disciple.  G.  Leubuscher  has 
found  a modification  of  Flechsig’s  treatment  to  be  of  service — 
opium  in  increasing  doses  for  six  weeks,  then  the  bromide  under 
the  form  of  bromipine,  a combination  of  10  per  cent,  bromine  with 
sesamol  {Monatsschrift  fiir  Psych,  u.  Neurolog.,  1899,  Bd.  v.).  Adonis 
vernalis  combined  with  bromide  (Bechterew’s  method)  is  in  some 
cases  decidedly  useful,  especially  when  there  exists  a neurasthenic 
condition  of  the  heart.  In  other  cases  I have  found  useful  a com- 
bination of  bromide  with  salicylate  of  soda  in  doses  of  i|-  to  2 
grammes  of  salicylate  with  3 to  5 grammes  of  bromide  in  twenty-four 
hours.  Some  writers,  amongst  them  Amedeo  in  Italy,  have  attributed 
a great  therapeutic  value  to  aintipyrine;  but  I have  not  succeeded 
in  persuading  myself  of  its  real  efficacy;  All  the  bromides  have 
been  tried,  and  all  have  found  their  exponents.  Smith  [Lancet, 
1899)  has  found  the  bromide  of  strontium  useful  in  epileptic  insanity, 
but  in  somewhat  larger  doses  than  the  bromide  of  potassium. 
Others,  again,  have  tried  injections  of  bromipine  with  some  measure 
of  success  (F.  Schulze,  Wulff,  Laugenhagen,  and  Bodoni). 

The  dose  of  bromide  varies  in  different  cases.  In  youths  and 
in  adults  we  may  certainly  regard  the  minimum  dose  as  3 grammes 
in  the  day,  which  may  be  increased  up  to  10,  and  even  more,  accord- 
ing to  the  results  obtained  and  the  tolerance  shown. 

There  are  individuals  who  tolerate  well  large  doses  of  bromide, 
and  there  are  others  (although  much  rarer)  who  either  do  not 
tolerate  similar  doses  or  derive  no  benefit  as  regards  the  frequency 
and  the  severity  of  the  epileptic  accessions.  In  such  cases,  to 
persist  in  the  bromide  treatment  is  apt  to  be  injurious,  and  there- 
fore it  is  well  to  abandon  it. 

The  abstraction  of  chlorides  from  the  food  (Toulouse)  has  not 
proved  a real  advance  in  the  treatment  of  epilepsy.  Nitrate  of 
silver,  arsenic;  and  especially  phosphorus  (also  in  the  form  of 
lecithin),  are  good  therapeutic  aids.  The  powders  and  fluids 
extolled  as  specifics  are  to  be  proscribed  by  self  - respecting 
physicians. 

When  epilepsy  is  produced  by  injuries  giving  rise  to  cerebral 

34—2 


532 


PSYCHIA  TRY 


compression  and  all  those  alterations  that  are  the  immediate  cause 
of  the  seizures,  as  well  as  the  accessions  of  insanity  that  are  often 
associated  with  the  convulsions,  it  is  necessary  to  remove  those 
causes  by  aid  of  surgical  intervention  (splinters  of  bone,  thickened 
membranes,  abscesses,  tumours,  cysts),  and  in  every  case  it  will  be 
well  to  incise  or  remove  a piece  of  the  dura  mater,  in  this  way 
leading  to  diminution  of  the  endocranial  pressure,  as  advised  by 
Kocher  (Archiv  fiir  klin.  Chirurgie,  Bd.  lix.)  and  Lambiasi. 

In  rare  cases,  even  when  the  epilepsy  is  associated  with  accessions 
of  post-epileptic  insanity  and  with  abnormal  phenomena  during 
the  interval,  recovery  may  take  place  in  consequence  of  a hemi- 
plegia caused  by  formation  of  a destructive  focus  during  a long  and 
severe  epileptic  attack,  as  happened  in  Brunet’s  case  {Archives 
de  Nevrologie,  1900). 

For  clearer  information  and  fuller  details  regarding  the  treat- 
ment of  epilepsy  in  general,  I refer  the  reader  to  Kowalewski’s 
splendid  work.  Epilepsia:  Traitement,  Assistance,  etc.,  1901,  and 
also  to  Pini’s  Uepilessia  : etiologia,  patogenesi  e cur  a,  1902. 

Not  long  ago  Ceni  claimed  to  have  found  that  the  serum  of 
epileptics  injected  into  epileptics  has  therapeutic  effects.  The 
serum  may  be  taken  either  from  the  epileptic  subject  himself  or 
from  another  equally  epileptic  (‘  Nuove  proprietd  tossiche  e tera- 
peutiche  del  siero  del  sangue  degli  epilettici  e loro  applicazioni 
pratiche,^  Rivista  Sperim.  di  Freniatria,  1901).  At  first  the  morbid 
syndrome  would  be  aggravated  (crisis  of  adaptation),  but  by 
degrees  the  accessions  would  become  diminished  in  frequency  and 
severity  or  would  entirely  disappear.  It  would  appear  that  only 
a few  cases  have  toxic  effects  been  noticed.  According  to  Ceni, 
the  blood  serum  of  epileptics  contains  both  toxic  substances  and 
beneficial  stimulants.  I a.m  not  in  a position  to  confirm  statements 
of  such  great  importance.  It  is  certain,  however,  that  they  have 
not  found  confirmation  in  the  researches  of  Roncoroni  {Archives  di 
Psich.  e Scienze  penali,  vol.  xxiii.),  nor  in  those  of  Sala  and  Rossi 
{Gazetta  Medica  Lombarda,  anno  Ixii.),  who  not  only  failed  to 
induce  by  that  method  any  favourable  influence  on  the  course  of 
the  disease,  but  did  not  even  observe  the  toxic  phenomena  described 
by  Ceni. 


CHAPTER  VII 


HYSTERICAL  INSANITY 

Although  all  the  manifestations  of  hysteria,  including  the  somatic, 
are  either  purely  psychic  phenomena  or  intimately  connected 
with  them,  we  shall  not  make  a complete  study  of  hysteria,  for 
that  would  lead  us  too  far  beyond  the  lim  ts  prescribed  by  the  nature 
of  this  work. 

It  is  certain  that  anaesthesia,  paralysis,  contractions,  blindness, 
deafness,  and  similar  phenomena  that  disappear  without  leaving 
any  trace,  under  the  action  of  a physical  agent,  or  under  the  influence 
of  an  emotion  or  of  some  form  of  suggestion,  irresistibly  lead  us  to 
think  that  there  is  an  altogether  peculiar  operation  of  the  brain, 
and  a lack  of  any  demonstrable  anatomo-pathological  substratum 
such  as  we  are  accustomed  to  meet  with  in  other  nervous  or  mental 
diseases  ; a gross  lesion  would  not  be  conceivable,  in  view  of  the 
rapidity  of  manifestations  like  these,  and  of  the  instantaneousness 
of  their  disappearance. 

This  is  not  the  place  for  a discussion  as  to  which  doctrine  is 
best  supported  by  facts — that  of  hetero-suggestion,  or  that  of  auto 
suggestion,  the  doctrine  maintained  by  Sollier  in  a very  meritorious 
work.* 

* It  is  worth  while  reproducing  here,  in  their  full  extent,  that  author’s 
ideas  upon  hysteria  : 

‘ We  have  seen,’  he  says,  ‘ that  emotional  disturbances  act  particularly 
upon  those  parts  of  the  body  that  are  susceptible  to  alteration  by  the  actual 
cause  of  the  emotion,  and,  on  the  other  hand,  that  all  emotion  induces 
anaesthesia  either  directly  or  through  reaction.  The  anaesthesia  which  is 
transient  in  normal  subjects  may  persist  in  those  predisposed  to  hysteria. 
The  anaesthesia  reaches  those  cortical  centres  that  correspond  to  the  organ 
to  which  the  sufferer  directs  his  attention  during  the  emotion.  This  anaesthesia 
is  nothing  else  than  torpor  or  sleep  of  those  centres  ’ (Sollier  : Genhe  et 
Nature  de  VHysterie,  2 vols.,  8vo.  Paris,  1897). 

According  to  Sollier  it  is  therefore  the  anaesthesia  that  produces  all  the 
phenomena  of  hysteria,  and  that  anaesthesia  may  exist  in  the  internal  organs 
when  it  is  not  found  in  the  skin.  Pierre  Janet,  on  the  other  hand,  regards  it 
as  a fixed  idea,  and  in  this  view  he  is  partly  opposed  by  Sollier.  The  fixed 
idea  exists  in  the  majority  of  cases — and  in  this  respect  I am  in  accord  with 

533 


534 


PSYCHIATRY 


It  is  of  little  interest  to  us  whether  a given  somatic  phenomenon 
is,  in  its  origin,  dependent  on  a dormant  state  of  the  respective 
centre  in  the  cerebral  cortex,  as  Sollier  says,  or  whether  it  is  pro- 
voked by  a fixed  idea — Janet’s  theory.  On  the  other  hand,  what 
is  important  to  establish  thoroughly  is  the  fact  that,  when  a 
somatic  phenomenon  of  hysteria  exists,  such  as  anaesthesia,  par- 
alysis, or  contractions,  the  respective  cortical  centre  is  not  performing 
its  functions  ; or  that  such  centre,  although  it  may  perform  its 
functions,  is  isolated  from  all  the  others,  and  particularly  from  the 
evocative  centre  in  the  frontal  lobe,  where  the  impression  of  the 
moment  is  brought  into  relation  with  analogous  impressions 
experienced  by  the  psychic  personality.  The  somatic  phenomena 
of  hysterical  subjects  are,  therefore,  clearly  psychic,  and  we  must 
consider  them  as  the  expression  of  a psychic  personality  whose 
functions  are  performed  defectively  and  abnormally.  As  a matter 
of  fact,  whenever  a zone  of  the  cerebral  mantle  is  in  that  state  the 
psychic  personality  is  altered.  All  individuals  who  show  more 
or  less  marked  signs  of  hysteria — and  that  practically  means  that 
a part  of  the  cerebral  mantle  is  either  isolated  from  the  working 
machinery  of  all  the  other  parts  or  is  working  excessively  (hyper- 
algesia)— present  a psychic  attitude  that  is  altogether  peculiar. 
This  has  been  well  defined  by  Pierre  Janet,  and  it  was  described 
by  myself  even  earlier  (Bianchi  : ‘ La  responsahilita  nelle  isteriche,' 
Rivista  Sperim.  di  Fren.,  1890). 

Functional  inhibition  or  sleep  of  a cortical  organ,  or  its  isolation, 
always  induces  a more  or  less  significant  mutation  of  the  personality. 

The  following  I communicated  to  the  Italian  Psychiatric 
Congress  at  Milan,  1889  : 

‘ There  are  hysterical  subjects  who  present  grave  somatic  signs  of 
their  malady,  such  as  paralysis,  contracture,  hemianaesthesia,  etc., 
and  even  although  they  suffer  but  rarely  from  hysterical  convul- 
sions, they  exhibit  a character  and  a complexity  of  psychic  features 
decidedly  different  from  those  manifested  previously  ; then,  although 
they  were  neuropathic  or  hysterical,  they  did  not  show  the  more 
persistent  signs  of  confirmed  and  grave  hysteria.  Such  a difference 
in  behaviour  and  conditions,  which  we  can  now  consider  with  cer- 


Janet — but  it  is  determined  by  the  somatic  hysterical  disturbance.  This 
represents  a point  of  concentration  for,  or  polarization  of,  the  mind  of  the 
hysterical  subject.  It  is  a subconscious  state  of  attention,  having  leference 
to  the  part  that  does  not  perform  its  function.  Frequently,  however,  it  is  a 
question  of  images  and  emotions  that  have  previously  occurred,  even  though 
at  a very  remote  period,  and  it  is  the  image  that  determines  the  form  the 
picture  will  take.  If  a hysterical  subject  has  once  seen  a paraplegic,  he  will, 
when  under  the  influence  of  an  emotion,  have  paraplegia,  with  or  without  con- 
vulsions. If  another  hysterical  subject  has  seen  an  attack  of  hemiplegia  or  of 
vomiting,  no  matter  at  how  distant  a period  of  his  life,  emotion  will  reproduce 
in  him  exactly  those  symptoms,  which  remain  in  the  background  of  the  mind 
of  the  hysterical  subject,  with  a high  reproductive  potential. 


HYSTERICAL  INSANITY 


535 


tainty  to  be  a,  form  of  what  is  known  in  its  most  classic  form 
as  “ duplication  of  the  consciousness,”  has  been  observed  by 
myself  in  five  out  of  seven  cases  ; two  of  these  I saw  in  the 
hospital  to  which  I was  attached  as  physician  at  Naples,  while 
three  were  observed  in  my  private  clinique.  Here  I shall  relate 
briefly  the  two  most  important  cases  that  came  under  my  notice, 
one  of  them  at  the  hospital  of  St.  Eligio,  and  the  other  in  the 
Ospedale  della  Vita  at  Naples.’ 

Observation  VII.— -N.  C.,  a woman  of  about  thirty  years,  married 
and  having  children,  was  received  into  the  hospital  of  St.  Eligio  ‘ for 
apoplexy,’  which  had  left  behind  it  complete  hemiplegia.  When  I was 
called  to  ecamme  this  patient,  and  possibly  to  apply  electric  treatment, 

I diagnosed  hysterical  hemiplegia,  hemianesthesia,  amblyopia,  dys- 
chromatopsia,  etc.  This  woman  always  appeared  to  be  extraordinarily 
merry,  thoughtless,  and  facetious.  She  was  of  an  enterprising  and 
insinuating  disposition.  She  won  the  love  of  the  other  patients  and  of 
the  Sisters.  She  was  moderate  and  agreeable  in  her  hilarity  ; she  seemed 
to  pay  no  heed  to  the  grave  paralysis ; and  by  contrast,  she  aroused  on 
all  sides  a strong  feeling  of  pity.  On  the  other  hand,  she  spoke  of  her 
husband  and  her  children  with  a lack  of  interest  all  the  more  surprising 
in  view  of  the  good  nature  that  illumined  her  countenance,  because  it 
symbolized  complete  affective  anaesthesia. 

She  would  also  speak  smilingly,  and  with  clear  signs  of  psychic 
anaesthesia,  of  the  misery,  the  squalor,  and  the  hunger  that  were  the 
torment  of  her  beggared  children  and  her  husband  (mild  hysterical 
mania).  After  she  had  been  cured  of  the  paralysis  by  a few  applications 
of  electricity,  she  became  more  composed  and  serious,  being  preoccupied 
with,  and  fully  conscious  of,  her  own  wretched  position  and  that  of  her 
family.  She  was  no  longer  facetious,  but  showed  herself  grateful  and 
rather  sad.  As  though  she  had  conceived  the  notion  of  a high  duty, 
that  hitherto  had  remained  outside  the  threshold  of  her  consciousness, 
she  asked  to  be  dismissed  in  order  to  look  after  her  family,  and  that  with 
a degree  of  solicitation  that  formed  a solemn  contrast  to  the  merry  and 
thoughtless  disposition  of  mind  she  displayed  so  long  as  she  was 
hemiplegic. 

Observation  VIII. — A young  woman  of  twenty-six,  of  fairly  good 
social  standing,  was  received  into  Ward  i of  the  Ospedale  della  Vita. 
For  seven  months  previously,  paraplegia  had  been  developing,  and  that 
had  been  preceded  long  before  by  convulsions  that  were  certainly  hysterical 
in  character. 

There  was  a slight  degree  of  muscular  flaccidity  ; both  anaesthesia* 
and  analgesia  were  present.  The  patellar  reflex  was  well  preserved  and 
normal,  while  the  electric  excitability  of  the  paralyzed  muscles  was  also 
normal.  With  such  a combination  of  symptoms  there  was  no  difficulty 
in  diagnosing  the  nature  and  the  hysterical  origin  of  the  paralysis, 
although  the  convulsions  had  not  recurred  since  her  admittance  to  the 
hospital,  nor  had  any  modifications  of  the  disease  been  noticed. 

After  not  more  than  six  applications  of  faradic  electricity,  while 
every  day  her  attention  was  called  to  those  muscular  movements  of  the 
thighs  and  legs  that  were  thus  provoked,  in  order  that  her  vision  might 
aid  in  recalling  the  images  of  movement,  and  reawaken  confidence  in 
her  own  muscles,  I adopted  one  morning  the  artifice  of  telling  her  that 
from  certain  signs  I had  reason  to  believe  that  she  would  be  cured,  and 
that  the  next  morning  she  would  rise  from  her  bed  without  any  assistance. 

The  suggestion  thus  made  had  a marvelous  effect,  for  the  following 


536 


PSYCHIATRY 


day  she  awoke,  jumped  out  of  bed,  ran  about  the  ward,  kissing 
the  other  patients,  and  proclaimed  her  own  complete  cure  with  inex- 
pressible joy.  A notable  change  in  her  mental  attitude  had  occurred. 
Throughout  the  whole  time  that  she  was  bedridden,  she  was  the  torment 
of  the  ward,  of  the  doctors  and  the  Sisters  who  attended  her.  She 
was  capricious,  discontented,  petulant,  selfish,  thankless,  troublesome, 
overbearing  and  indifferent  to  the  sufferings  of  her  companions  in  mis- 
fortune. She  experienced  an  irresistible  desire  to  attract  towards  herself 
alone  the  interest  and  the  care  of  the  doctors  and  of  the  nurses.  She 
would  constantly  alternate  from  weeping  to  laughter,  and  vice  versa, 
although  both  manifestations  were  illogical,  both  in  origin  and  duration. 
When  the  paralysis  disappeared  she  was  quite  another  woman,  being 
modest,  affable,  of  good  disposition,  ready  to  help,  and  generous. 

These  two  patients  were  certainly  not  cured  of  their  hysteria,  and 
therefore,  after  the  disappearance  of  the  most  persistent  and  durable 
manifestation  of  the  trouble,  they  were  not  perfectly  reintegrated  in  their 
original  personalities.  Not  that  any  grave  disturbance  of  their  con- 
sciousness happened  to  be  manifested  during  the  somatic  illness,  for 
neither  defect  of  memory  nor  break  of  continuity  in  the  thread  of  their 
psychic  lives  had  been  noticed  ; still,  without  any  doubt,  a new  and  unusual 
direction  given  to  their  moral  character  and  their  affections,  introduced 
grave  disorder  into  the  whole  of  their  mental  lives. 


The  somatic-  phenomena  of  hysteria,  which  show  great  variety 
and  mobility,  find  their  counterpart  in  the  psychic  character, 
which  reproduces  essentially,  though  under  another  form,  the 
mobility  and  the  variety  of  the  somatic  phenomena.  These  two 
orders  of  facts  both  prove  the  weak  affinity  between  the  various 
elements  that  constitute  the  psychic  personality  of  the  hysterical 
subject  ; that  is  to  say,  the  affinity  between  them  being  feeble, 
there  is  weakened  discipline  as  regards  the  relations  of  the  various 
cerebral  departments,  which  ought  to  concur  harmoniously  to  allow 
the  personality  to  find  its  expression.  The  result  of  this  harmonious 
co-operation  is  manifested  in  what  we  call  character.  The  funda- 
mental traits  of  character  in  each  person,  evident  in  all  the  various 
stations  in  life,  owe  their  uniformity  to  the  solidity  of  the  relations 
between  the  various  cerebra.1  parts. 

Here  also,  as  in  epilepsy,  we  are  obliged  to  call  to  our  aid  a 
dynamic  doctrine,  recognising  the  possibility  of  an  excessive  change 
of  the  dynamic  potential  required  for  the  functions  of  the  separate 
parts  of  the  brain,  of  which  the  various  departments  are  charged 
and  discharged  alternately,  contrary  to  what  happens  in  epilepsy. 

In  correspondence  with  the  fact  that  anaesthesia  and  hyper- 
aesthesia  occur  in  turns,  and  that  the  paralysis  pa.sses  into  con- 
tracture and  the  contracture  disappears  from  one  member  to 
present  itself  in  another,  the  moral  and  intellectual  character 
of  the  hysterical  subject  furnishes  an  example  of  paradoxical 
contrasts  between  mentaJ  states  that  are  utterly  opposed  to  each 
other.  Without  any  apparent  external  cause,  hysterical  subjects 
pass  from  joy  to  sadness,  from  laughter  to  weeping,  from  love  to 
hatred,  from  timidity  to  temerity,  from  utter  lack  of  will  to  decisive 


HYSTERICAL  INSANITY 


537 


enthusiasm.  Tardieu,  Lasegue,  Legrand  du  Saulle,  Schiile  and 
Jolly,  among  others,  who  have  made  a profound  study  of  the  moral 
character  of  hysterical  subjects  and  of  their  psychic  constitution, 
apart  altogether  from  hysterical  insanity,  all  express  the  same 
opinion.  They  present  the  same  picture,  coloured  with  the  same 
tints,  of  the  motives  that  influence  the  minds  of  hysterical  subjects. 
That  picture  has  been  reproduced,  corrected,  and  copied  by  other 
noted  writers,  and  it  represents,  in  an  appreciable  form,  a scientific 
fact  that  is  thoroughly  established. 

The  predominant  note  is  one  of  exaggerated  affective  excit- 
ability, which  resolves  itself  into  a series  of  acts  through  circuits, 
upon  which  the  inhibiting  power  that  ema.nates  from  the  higher 
cerebral  centres  has  no  effect.  Those  centres,  very  little  developed 
originally , are  absolutely  prevented  from  performing  their  functions 
by  the  lower  centres,  which  are  overcharged  at  high  tension. 
The  activity  of  these  latter  is  altogether  put  at  the  service  of  the 
inferior  ego  (egocentric),  and  the  inferior  ego,  exposed  to  all  in- 
fluences, uncontrolled  and  uncontrollable,  internal  and  external,  is 
changeable  by  reason  of  the  non-operation  of  the  regulative  centres, 
which  are  the  true  depositories  of  historical  experience  ; and  in 
conformity  with  the  law  of  adaptation  and  of  conservation  of  the 
personality,  that  experience  it  is  which  regulates  eonduct.  Affective 
irritability,  vibrating  under  slight  stimuli,  gives  us  the  key  to  those 
sensory  judgments,  almost  reflex  and  uncontrolled,  and  therefore 
explains  the  illogical  sympathies  and  antipathies. 

In  no  other  subjects  is  the  law  of  contra.st  so  wonderfully  mani- 
fested as  in  hysterical  persons.  Owing  to  the  fantastic  representa- 
tion of  opposite  images,  strictly  connected  one  with  another,  chasing 
one  another  through  the  consciousness,  the  orientation  of  the  mind 
is  altered,  its  intonation  changes,  and  sympathies  and  antipathies 
occur  alternately,  with  attraction  and  repulsion  for  the  same 
persons  or  the  same  things. 

The  free  course  allowed  to  these  tendencies,  which  meet  with 
no  obstacle  in  the  consciousness,  as  the  inhibitory  powers  do  not 
act,  causes  hypertrophy  of  the  ego  in  this,  its  new  direction  ; and 
while,  on  the  one  hand,  the  subjects  shake  themselves  free  of  all 
restraints  due  to  social  relations,  such  as  duties,  respect  or  pity 
for  others,  they  have  an  insane  desire  to  excite  interest  and  to 
draw  upon  themselves  the  great  interest  of  those  around,  with  which 
object  they  resort  to  every  degree  of  originality  and  of  paradox 
that  their  minds  can  conceive,  sometimes  exaggerating  their 
sufferings  with  the  aid  of  the  sharpest  trickery.  Thus  it  comes 
about  that  persons  affected  by  hysteria  have  an  irresistible  liking 
for  deception.  With  their  double-dealing  and  lying  they  carry 
their  mystifications  to  such  a degree  that  they  can  mislead  the 
keenest  observers.  They  make  false  accusations  against  persons 
for  whom  they  feel  an  invincible  antipathy,  which  in  most  cases 


538 


PSYCHIATRY 


has  no  justification  at  all,  and  they  support  their  accusations  with 
a web  of  tales  that  are  absolutely  imaginary,  but  so  well  woven  | 
together  that  they  give  the  story  an  air  of  verisimilitude,  and  render 
it  very  credible  indeed.  They  lie,  not  always  for  the  pleasure  of 
lying,  and  their  impulse  to  deception  is  sometimes  so  exalted  as 
to  become  a delirium  (Lasegue).  They  are  exceedingly  egotistical, 
and  according  to  their  degree  of  culture  and  the  surroundings  in 
which  they  live,  the}^  will  attempt  to  interest  the  persons  about 
them  or  the  whole  population  of  a country.  i 

To  satisfy  this  irresistible  craving  they  often  go  through  most  j 
grotesque  performances  on  the  stage  of  life,  and  in  the  days  in  | 
which  we  are  living  they  will  frequentl}/  deliver  their  tales  through 
the  medium  of  newspapers,  which  are  often  the  willing  servants 
of  triumphant  vanity,  that  vanity  itself  being  the  expression 
of  psychic  degeneration.  These  true  representatives  of  ‘ over- 
sensitiveness ’ always  find  a suitable  stage  on  which  to  play  their 
parts. 

It  is  this  spirit  of  contradiction  and  this  mania  for  exciting  the  : 
interest  of  the  public  that  drive  some  hysterical  subjects,  even  the 
most  intelligent  of  them,  to  give  themselves  up  to  charitable  and 
generous  undertakings.  Whether  it  be  that  a strong  feeling  of 
pity  arises  through  the  law  of  contrast,  or  whether  religious  feeling  ’ 
is  predominant,  or  if,  again,  it  is  tormenting  vanity  that  imperiously  •' 
demands  the  performance,  they  display  unexpected  altruism,  r 
subscribing  to  associations  for  protecting  the  weak,  visiting  hos-  ' 
pitals,  founding  new  charities,  or  joining  in  the  work  of  existing  ii; 
ones.  They  go  about  with  much  activity,  and  figure  as  great  ! 
benefactors ; and  they  are  so,  although  their  motive  is  simply 
exaggerated  egoism. 

Sometimes  hysterical  subjects  create  for  themselves  deities,  to  . 
which  they  sacrifice  their  persons  in  religious  zeal ; or  they  imagine  ^ 
demons,  to  whom  they  give  the  form  and  figure  of  those  unfortunate  ] 
persons  who  have  incurred  their  illogical  antipathy,  and  with  ' 
whom  they  find  themselves  in  conflict  for  various  reasons.  ; 

Then,  they  make  false  accusations,  and  in  their  exalted  fancy  i 
they  find  the  most  brilliant  colours  in  which  to  set  forth  their  case  ! 
before  the  courts  of  justice  and  to  fascinate  judges  and  juries.  i| 
Such  an  antipathy  for  certain  persons  may  become  the  first  cause  if 
of  criminal  acts,  the  carrying  out  of  which  occupies  and  dominates  S 
the  whole  of  their  consciousness  like  a fixed  idea.  According  to  j 
a clever  expression  of  Esquirol,  this  is  a species  of  ‘ catalepsy  of  | 
tire  souk’  This  idea  was  made  use  of  many  years  after  by  Janet.  || 

Such  subjects  are  masters  in  astuteness,  a,nd  they  practise  ' 
every  refinement  of  simulation.  Their  irresistible  desire  to  make 
themselves  interesting  urges  them  to  concoct  grotesque  and 
ridiculous  comedies,  which  bring  trouble  into  honourable  families, 
emd  sometimes  have  a tragic  ending.  In  these  cases  no  small  part 


HYSTERICAL  INSANITY 


539 


is  played  by  anonymous  letters,  which  they  write  in  order  to  make 
trouble  and  sow  discord  (Dally). 

If  it  be  true  that  the  end  justifies  the  means,  the  hysterical 
subject  makes  the  most  ample  and  insane  application  of  this  doc- 
trine. To  execute  his  intention,  which  is  generally  egoistic,  he 
indulges  the  strangest  ideas,  and  hatches  most  dangerous  plots, 
which  he  thoughtlessly  puts  into  effect.  In  a fa.mily,  hysterical 
subjects  sometimes  disturb  the  domestic  peace,  claiming  proofs 
of  affection,  which  the}^  will  often  reject,  particularly  from  their 
husbands,  against  whom  they  will  inveigh  unceasingly  in  their 
aggressive  spirit  should  they  meet  with  the  slightest  contradic- 
tion. In  their  teeming  imagination  they  organize  slanders  and 
accusations,  and  they  maintain  them  even  before  courts  of  justice, 
in  certain  more  or  less  scandalous  actions  for  separation.  Their 
lucidity  is  such,  and  they  speak  with  such  an  accent  of  conviction, 
that  they  influence  judges  in  their  favoui. 

With  their  spirit  of  contradiction  and  controversy,  their  duplicity 
and  simulation,  their  inveterate  and  incessant  need  of  tying  without 
any  interest  to  serve,  they  take  advantage  of  the  strangest  and 
most  inconceivable  means  and  occurrences.  ‘ They  abandon  them- 
selves to  the  most  unjust,  ridiculous,  false  and  bizarre  suppositions. 
As  the  love  of  truth  is  not  in  any  way  the  predominating  virtue  of 
their  characters,  they  never  relate  facts  as  they  realty  happen,  and 
they  deceive  husbands,  parents,  confessors  and  doctors  ’ (Morel). 

The  acuteness  and  the  unheard-of  boldness  wTich  women 
affected  by  grand  hysteria  will  display  in  order  to  deceive  are 
astonishing,  and,  says  Charcot,  particularly  when  the  doctor  is 
to  be  the  victim  of  their  imposture. 

The  intellect  of  hysterical  subjects  is  not  of  a superior  order — 
almost  never  so.  There  is  an  appearance  of  vivacity  and  of  readi- 
ness in  many  cases,  but  neither  soundness  nor  continuity  of  reasoning 
or  of  action  is  to  be  found  underlying  that  phosphorescence,  which 
is  often  deceitful.  The  powers  of  perception  are  sometimes  mar- 
vellously fine,  and  they  are  utilized  in  reading  the  thoughts  of  other 
people,  as  is  proved  by  the  interesting  studies  of  Tamburini,  Guic- 
ciardi  and  Ferrari  on  this  subject.  That  keenness  of  perception 
enables  the  hysterical  subject  to  feel  stimuli,  which,  owing  to 
distance  or  feebleness,  never  approach  the  threshold  of  the  per- 
ception, or  even  attract  the  simple  notice,  of  the  generality  of  men.* 

Such  keenness  of  perception  generally  remains  isolated,  and  in 
no  wise  does  it  form  an  integral  part  of  the  intellect,  which  appears 
rather  to  remain  a complacent  spectator  of  a phenomenon  that 

* Among  other  cases,  I remember  one  of  a young  woman,  blind  (hysterical 
amblyopia),  and  paraplegic,  with  left  hemiansesthesia.  One  day  she  heard 
the  various  pieces  of  music  that  were  being  played  by  some  of  her  cousins 
who  lived  more  than  one  and  a quarter  miles  away.  This  fact  was  thoroughly 
inquired  into  and  verified. 


540 


PSYCHIATRY 


is  extraneous  to  the  formative  process  of  the  series  and  the  syntheses 
of  thought. 

These  subjects  are  credulous  and  susceptible  to  suggestion.  A 
person  who  is  master  of  himself  changes  his  thoughts,  convictions, 
actions  and  mental  phenomena  at  will  ; but  the  mind  of  some 
hysterical  subjects  is  as  the  keyboard  of  a piano,  capable  of  being 
performed  on,  so  that  from  it  the  skilled  artiste  can  draw  motives 
for  the  most  opposite  emotions,  different  in  tone  and  in  character. 
For  this  same  reason  these  people  are  more  disposed  than  any  others 
to  imitation  : hence  the  readiness  with  which  hysteria  became 
epidemic,  especially  among  girls  in  schools.  Notable  examples  are 
also  to  be  found  in  the  history  of  the  Middle  Ages  (Guislain,  Abri- 
cossoff,  Bianchi). 

Their  attention  has  no  fixity.  Automatism  predominates  much 
more  than  in  epilepsy.  The  very  interesting  studies  of  Binet  and 
Janet  on  ‘ the  unconscious  ’ were  made  on  hysterical  subjects. 
The  attention  is  weak,  flighty,  interrupted,  and  is  exhausted  in  a 
very  much  shorter  time  than  in  normal  individuals,  except  in  the 
case  of  matters  that  have  a direct  bearing  on  the  personality  or  the 
views  of  the  hysterical  subject. 

Every  person  will  understand  how  much  this  factor  contributes 
to  the  fiequency  of  errors  in  their  judgment  of  persons,  circum- 
stances, and  things. 

Their  memory  is  halting,  unreliable,  and  sometimes  confused. 
A hysterical  subject  lacks  the  faculty  of  bringing  an  event  into 
relation  with  its  circumstances  of  time,  place,  and  person.  As 
her  fancy  is  very  fertile  in  products  that  are  inherent  to  the  theme 
that  actually  besets  her  mind  (hysterical  monoideism),  and  as 
these  new  products  are  represented  with  much  vividness,  there  may 
very  easily  arise  a transformation  of  the  reality,  more  or  less  altered 
by  the  fantastic  additions. 

Certainly  all  hysterical  subjects  do  not  present  this  morbid 
picture,  nor  are  the  lies  always  a product  of  their  wills.  In  most 
cases,  on  the  contrary,  as  Pitres  was  the  first  to  note,  it  is  a question 
of  vivid  imaginative  representations  ; or  there  are  highly-coloured 
representations,  subsequently  taken  for  reality,  owing  to  a par- 
ticular state  of  the  memory  ; or  it  may  be  that  dreams  have  left 
obscure  records,  but  still  sufflcient  to  determine  actions  in  which  the 
hysterical  disposition  finds  pleasure. 

It  is  these  peculiarities  of  the  hysterical  mind — mobile,  subject 
to  emotion,  fantastic,  dreaming,  egoistic,  dramatical,  and  prone 
to  duplication — that  give  rise  to  hysterical  delinquency,  a form  of 
moral  insanity  that  has  its  own  quite  peculiar  character,  and  which 
it  is  worth  while  to  illustrate  here  by  some  observations. 

Observation  IX. — On  the  evening  of  January  3,  1885,  Paolo  Conte, 
student  of  theology,  in  his  twenties,  belonging  to  Castellamare,  told 
how,  as  he  was  returning  from  a walk  and  had  reached  the  neighbourhood 


HYSTERICAL  INSANITY 


541 


of  his  own  house,  he  was  attacked  by  three  individuals.  One  of  them, 
after  referring  to  the  doings  of  the  Bishop,  to  magnetism  (hypnotic),  and 
to  the  opuscle  of  Dr.  Fusco,  gave  him  a heavy  blow  under  the  chin  ; 
the  second  struck  him  over  the  hat  with  a stick,  and  when  Conte  took  to 
flight,  discharged  a pistol  at  him,  but  missed  ; lastly,  the  third  aggressor, 
who  was  found  standing  against  the  corner  of  his  house,  said  to  Conte, 

‘ You  have  given  the  name  of  Palmigiano,’  and  at  the  same  time  struck 
at  his  chest  with  a dagger.  The  unlucky  Conte  managed  to  parry  that 
thrust  with  his  umbrella,  and  so  got  off  uninjured. 

The  attack  had  been  preceded  by  anonymous  letters,  and  as  soon  as 
the  first  of  those  threatening  letters  reached  Conte,  he  suspected  that  the 
author  of  them  was  the  priest  Giuseppe  Palmigiano,  for  Palmigiano  had 
shown  hostility  to  Conte  as  soon  as  ever  the  story  of  his  cure  by  means  of 
magnetism  had  got  abroad. 

Palmigiano  had  also  urged  Conte’s  mother  to  make  him  divest  himself 
of  the  sacerdotal  habits,  and  that  matter  was  referred  to  in  one  of  the 
anonymous  letters.  These  suspicions  became  almost  a matter  of  cer- 
tainty when  Conte  heard  one  of  his  aggressors  mention  the  name  of 
Palmigiano,  a former  secretary  of  the  Catholic  Society  of  Castellamare, 
and  editor  of  the  paper  La  Guida  delV  Operaid,  which  journal  was  doing 
its  utmost  to  discredit  the  magnetic  or  hypnotic  cure,  in  order  to  revive 
the  efficacy  of  the  miracle  worked  by  Pius  IX. 

As  a matter  of  fact,  Paolo  Conte,  who  was  of  a timid  nature  and  not 
very  old,  apart  from  being  an  invalid,  was  absolutely  incapable  of  offering 
any  resistance,  so  that  his  three  supposed  aggressors,  who  were  strong 
and  robust  men,  armed  with  daggers  and  firearms,  had  no  great  obstacle 
to  overcome  in  carrying  out  their  criminal  intention  to  murder  him  had 
they  wished  to  do  so.  The  three  men  informed  against  were  sent  for 
trial  before  the  Correctional  Tribunal  of  Naples. 

After  this  first  attack,  of  which  the  story  was  told  by  him  in  detail, 
Conte  thought  it  advisable  to  go  away  from  Castellamare,  and  took 
a room  in  Torre  x\nnunziata,  in  order  ‘ to  escape  the  wrath  of  his  enemies 
but  notwithstanding  that  precaution,  on  the  evening  of  February  6,  as 
he  was  returning  home,  he  was  again  attacked  by  an  unknown  man. 

The  circumstances  of  this  attack  deserve  to  be  told  in  some  detail. 
To  secure  his  safety,  he  lived  in  Torre  Annunziata  under  the  special 
protection  of  the  police.  On  the  morning  of  the  6th  he  wished  to  go  to 
Castellamare,  and  the  policeman  accompanied  him  to  the  station. 
When  Conte  returned  from  Castellamare  the  policeman  was  at  the 
station  to  meet  him  and  accompany  him  back  to  his  house.  However, 
when  the  two  had  got  to  within  a little  distance  of  Conte’s  house,  the 
latter  expressed  his  desire  to  call  on  a friend,  and  as  he  intended  to  remain 
for  some  time,  he  dismissed  the  policeman,  saying  that  his  room  was  only 
a few  steps  away,  and  that  he  would  be  all  right. 

When  he  was  going  home  some  time  later,  and,  according  to  his  story, 
after  he  had  passed  the  alley  at  the  side  of  the  palace  and  drawn  near 
to  the  lamp  that  shone  upon  the  stairs,  in  order  to  see  what  time  it  was, 
an  unknown  person  snatched  away  his  watch,  which  he  was  holding  in 
his  hands,  and  then  struck  him  repeatedly,  saying,  ‘ You  gave  the  name 
of  Valenzano.  Remember  that  he  belonged  to  us,  and  give  these  blows 
to  Fusco — give  them  to  Fusco!’  Conte  attempted  to  justify  himself, 
but  he  was  not  listened  to.  Instead,  he  got  a cut  with  a knife  on  his 
left  arm  from  the  aggressor,  whereupon  the  young  student  ran  up  the 
stairs;  but  just  as  he  reached  the  last  step  he  fell,  and  his  aggressor 
discharged  firearms  at  him,  but  did  not  injure  him. 

This  story  of  the  two  attacks,  as  related  by  Conte,  formed  the  basis 
of  the  accusation  and  trial. 

Previous  History. — His  mother,  when  young,  suffered  from  hysterical 


542 


PSYCHIA  TRY 


convulsions.  No  other  member  of  the  family  showed  any  noteworthy 
signs  of  neuropathia  or  psycho pathia. 

The  intellectual  development,  the  tendencies  and  the  character  of 
Conte  during  childhood  and  adolescence,  disclosed  no  items  of  interest. 
There  was  nothing  notable  to  be  observed  in  his  case  until  he  reached  the 
age  of  eighteen  years.  On  the  contrary,  according  to  the  report  of  Dr.  S., 
attached  to  the  seminary  of  Castellamare,  he  had  been  a very  docile 
and  studious  youth,  so  much  so  that  an  exception  was  made  in  his  case, 
and  he  was  allowed  to  take  the  minor  Holy  Orders  all  at  once,  instead  of 
successively,  at  regular  intervals,  in  the  mode  prescribed  by  rule. 

It  is  difficult  to  ascertain  anything  as  to  his  sexual  life.  According 
to  his  own  story,  which  he  told  with  complacent  simplicity,  it  would 
appear  that  up  till  now  he  has  turned  a deaf  ear  to  all  the  flattering  words 
of  Love.  He  himself  explains  that  in  his  own  way.  On  his  admittance 
to  the  seminary  he  saw  a youth  who  suffered  from  haemoptysis,  and  who 
died  of  that  malady.  A companion  told  him  that  the  deceased  was  a 
victim  of  onanism,  and  Conte  was  horror-stricken  at  the  revelation. 

Five  years  previously,  as  the  result  of  a fright,  he  had  a certain 
trembling  that  lasted  for  some  time.  He  was  still  in  the  seminary,  and  had 
had  some  words  with  some  of  his  comrades,  with  the  result  that  he  felt 
that  his  amour  propre  had  been  wounded.  The  resulting  emotion  was 
so  great  that,  for  the  first  time,  he  was  seized  with  convulsions,  completely 
losing  consciousness  and  amnesia. 

When  he  recovered  from  the  attack,  the  particulars  of  which  have 
not  been  recorded,  his  right  hand  was  contracted.  Three  days  after- 
wards the  contracture  extended  also  to  the  upper  part  of  his  left  arm,  so 
that  he  required  assistance  in  feeding.  At  the  same  time  there  appeared 
in  the  contracted  limbs  a trembling,  comparable  to  wide  oscillations, 
while  a certain  psychic  disturbance  manifested  itself,  for  he  was  tormented 
by  the  fixed  idea  of  the  offence  that  he  had  suffered  and  of  the  hurt  to 
his  self-esteem. 

He  remained  in  that  state  for  five  months,  during  which  time  fresh 
convulsions  supervened,  always  of  the  same  type,  and  they  increased 
in  frequency,  until  several  occurred  every  day. 

He  had  already  had  to  leave  the  seminary.  The  contractures  dis- 
appeared, but  the  trembling  remained  (hysterical  tremor  ?).  He  was 
therefore  prevented  from  continuing  his  studies,  and  his  ecclesiastical 
career  was  interrupted  ; but  one  evening,  whilst  his  family  were  repeating 
the  rosary,  he  fell  asleep  and  dreamt,  acccording  to  his  own  story,  ‘ that 
he  had  a vision  of  Pius  IX.,’  who  told  him  that  he  would  be  cured  of  his 
malady  if  he  touched  an  object  that  had  belonged  to  the  Pope.  The 
following  morning  he  went  to  the  Bishop  and  told  him  of  the  vision 
that  he  had  had  the  previous  evening.  Monsignore,  who  was  a shrewd 
man,  assured  him  that  there  was  nothing  at  all  strange  in  what  he  had 
just  recounted,  and  presented  to  him  an  autograph  of  Pius  IX.,  inviting 
him  with  religious  authority  to  touch  that  signature  of  the  Pope.  As  soon 
as  Conte  had  done  so  he  was  cured  of  the  tremor  in  the  upper  limbs. 
In  his  interrogatory  he  asserted  that  such  an  idea  had  never  passed 
through  his  mind,  and  that  no  one  had  ever  suggested  it  to  him. 

This  miracle  was  noised  abroad  and  made  a great  sensation  in  Castel- 
lamare and  beyond.  The  fanatical  Catholics  magnified  the  matter  and 
shouted  ‘Hosannah  !’  while  they  sent  Paolo  Conte  on  a mission  to  Pope 
Leo  XIII.  At  the  Vatican  he  was  cordially  received  by  the  Pope  and 
the  Cardinals.  They  gave  him  kisses  and  gifts,  counsel  and  encourage- 
ment, and  the  youth  returned  to  Castellamare  intoxicated  with  faith 
and  with  vanity,  and  apparently  extremely  happy  at  being  able  to  resume 
his  interriqited  ecclesiastical  career.  But  before  seven  or  eight  days 
had  passed  Paolo  was  again  seized  by  a convulsion,  on  recovering  from 


HYSTERICAL  INSANITY 


543 


which  his  upper  limbs  were  so  severely  contracted  that  others  had  to 
feed  him.  The  convulsions  continued,  always  with  the  same  charac- 
teristics, while  there  also  appeared  spasmodic  paraplegia  of  the  lower 
limbs,  which  lasted  for  four  or  five  months. 

When  he  was  in  this  condition  he  met  Dr.  Fusco  at  the  house  of  a 
family  of  his  acquaintance.  The  doctor  assured  him  that  he  could 
effect  a cure  by  magnetism,  and  when  Conte  had  consented  he  removed 
the  contracture  of  the  hands  in  a few  minutes.  ‘ At  that  moment,’  said 
Conte  in  his  interrogatory,  ‘ I could  not  believe  in  my  own  existence, 
and  I was  afraid  that  Fusco  was  really  possessed  by  a devil.  I was  in 
fear,  and  I hid  from  Fusco  the  paraplegia  of  the  lower  limbs.  I was 
satisfied  for  the  moment  with  regaining  the  use  of  the  hands,  and  as  for 
the  rest  I trusted  to  the  future.’ 

Still  there  was  no  recovery,  and  Paolo  determined  to  resort  again  to 
the  magnetic  cure  of  Dr.  Fusco.  With  a few  magnetic  passes  the  doctor 
cured  the  contracture  of  the  lower  limbs  at  one  interview.  When  the 
contractures  had  disappeared,  it  seemed  to  Conte  that  there  was  no 
longer  any  obstacle  in  the  way  of  his  continuing  his  studies  and  his 
ecclesiastical  career.  He  therefore  presented  himself  to  the  Bishop  to 
inform  him  of  his  cure.  The  Bishop,  however,  told  him  that  he  was 
possessed  by  a devil,  and  reproached  him  bitterly  with  trusting  to  the 
magnetic  cure.  He  ordered  him  to  divest  himself  of  his  sacerdotal  habits. 

It  is  difficult  to  say  what  impression  was  left  on  Conte’s  mind  by  the 
words  of  the  Bishop,  but  it  is  certain  that  when  Conte  returned  home  he 
was  again  seized  b}^  convulsions,  which  recurred  seven  or  eight  times  in 
a day,  this  continuing  for  more  than  a fortnight.  When  he  had  got  over 
these,  on  the  advice  of  Dr.  Fusco,  he  went  again  to  the  Bishop  to  lay 
before  him  his  very  ardent  desire  to  become  a priest ; but  Monsignore  was 
firm  m his  refusal,  and  as  Conte  was  leaving  the  Bishop’s  house  he  was 
seized  by  convulsions  in  the  hall.  These  were  followed  by  catalepsy, 
and  he  continued  in  a cataleptic  state  almost  the  whole  night.  Towards 
morning  he  was  carried  to  his  own  house.  Fusco  came  at  once,  and 
‘ his  magnetism  ’ freed  the  patient  from  the  catalepsy. 

In  the  meanwhile  grotesque  anonymous  letters  were  passing,  threaten- 
ing Paolo,  his  father,  the  Bishop,  Dr.  Fusco,  and  others.  Here  are  some 
of  them  : 

Anonymous  Letter  addressed  to  Paolo  Conte,  and  attributed  to  the  Priest 

Pahnigiano. 

‘ Casteli.amare, 

3,  1885. 

‘ Paolo, 

‘ Thou  bearest  the  name  of  an  apostle,  but  thy  deeds  are  not  the 
apostle’s  deeds,  nor  are  the  actions  of  thy  life.  Recover  thy  belief  ; hear 
my  counsel,  for  if  thou  listenest  to  me  thou  wilt  find  salvation  both  of 
mind  and  of  body.  Thou  art  far  from  the  truth.  Thine  eyes  are  blinded, 
and  thou  rushest  to  perdition.  Such  has  been  thy  conduct  that  the  way 
of  the  priesthood  is  closed  against  thee  ; put  oft  the  device  of  Christ, 
for  the  malignant  influence  of  the  abyss  weighs  thee  down. 

‘ Thou  art  a brazen-faced  fellow,  a liar,  a hypocrite ; and  thinkest 
thou  to  conceal  thy  nefarious  character  with  the  habit  that  thou  wearest  ? 
Thou  art  mistaken,  for  all  is  known,  and  the  earth  itself,  even  the  very 
mud,  rises  up  to  bear  testimony  against  thee,  who  art  rejected  of  Nature, 
of  man,  and  of  God. 

‘ Thou  remainest  obstinate  in  keeping  up  a part  thou  hast  played 
two  years  or  more.  Who,  thinkest  thou,  will  tear  that  habit  from  thy 
back  ? Certainly  it  will  come  to  that,  for  thy  dishonourable  and  squalid 
person  has  filled  the  measure  full  to  overflowing. 


544 


PSYCHIATRY 


‘ Thou  art  lost  ! It  is  true  that  the  mercy  of  God  is  great,  but  thine 
iniquities  have  exceeded  it,  and  therefore  thou  must  be  abandoned  to 
thy  fate,  which  now  I predict  for  thee  : 

Thou  wilt  sink  from  stage  to  stage  of  evil  until  thou  fullest  into  the 
abyss,  and  no  tidings  of  thee  shall  ever  more  be  heard.  I make  the  sign 
of  the  cross.’ 

Anonymous  Letter. 

‘ Rid  thyself  at  once  of  that  devil  of  a friend  of  thine — or  death  ! 

‘ The  Church  will  ever  triumph. 

‘ Our  Bishop  will  always  rule. 

‘ We  all  of  us  have  been,  and  still  are,  and  shall  be,  strong  to  combat. 

‘ Thou  wilt  meet  thine  end  at  our  hands. 

‘ The  truth  of  this  will  soon  be  found. 

‘ BLOOD  !’ 

Anonymous  Letter. 

‘ God  wills  it. 

‘ Time  will  pass. 

‘ Thou  wilt  not  be  carrying  an  umbrella. 

‘ We  obey.’ 

Anonymous  Letter. 

‘ Evangelizo  tibi  gaudium  magnum. 

‘ Thou  hast  escaped  once.  The  time  will  pass,  but  no  word  shall 
be  spoken.  Turn  thee  at  all  costs. 

‘ Throw  off  that  habit,  depraved  creature  ! God  wills  it,  and  human 
strength  cannot  stay  the  just  wrath  of  the  mighty  Creator  of  the  universe.’ 

AnonymoiLS  Letter  addressed  to  Paolo  Conte,  attributed  to  the  Priest 

Pahnigiano. 

‘ Sir, 

‘ You  are  a rascal  in  every  respect,  and  you  will  not  listen  to 
anyone  who  would  show  you  how  to  do  right.  It  will  be  the  worse  for 
you,  because  from  now  I shall  no  longer  indulge  in  words,  but  shall  pass 
on  to  deeds.  If  you  do  not  wish  a mighty  hurricane  to  burst  upon  you, 
put  off  that  habit  ; then  you  may  have  dealings  with  the  devil,  or  with 
whomsoever  you  please.  You  are  unworthy  to,  and  you  must  not, 
become  a priest.  This  I tell  you  in  God’s  name,  and  this  I shall  maintain. 

‘ You  are  a shameless  fellow,  a scoundrel,  a debauchee,  and  a liar: 
therefore  I cannot  suffer  Christ’s  flock  to  have  in  its  midst  a fellow  who 
represents  everything  that  is  most  disgraceful  and  abominable. 

‘ Brazen  and  shameless  wretch ! whom  do  you  expect  to  take  that 
habit  off  you  ? Will  you  force  me  to  make  your  dishonourable  and 
blameworthy  life  a matter  of  public  talk  ? Well,  I assure  you  that  I 
shall  do  so.  Go  to  the  devil,  for  only  there  will  you  find  yourself  at  home ; 
for  as  to  your  endeavour  to  keep  up  an  appearance  of  honesty,  I assure 
you  that  you  are  flattering  yourself  if  you  think  it  successful. 

‘ Shameless  and  disgraceful  wretch  that  you  are,  take  off  the  priestly 
habit,  and  go  and  live  the  life  of  an  assassin  ; for  that  you  were  born, 
and  thither  your  malignant  star  is  leading  you.  You  will  see  me  again, 
and  that  will  be  a terrible  moment  for  you.’ 

Another  Anonymous  Letter. 

‘ Villain, 

‘ Have  done  with  this  ; otherwise  we  shall  put  an  end  to  it.  Although 
you  escaped  the  first  time,  think  not  to  escape  again.  Confess  yourself, 
and  put  an  end  to  the  whole  thing. 

‘ God  is  always  with  us,  and  we  shall  not  abandon  our  task,  because 
we  are  sons  of  God.’ 


HYSTERICAL  IH SANITY 


545 


Anonymous  Letter  to  Michele  Conte,  the  Father  of  Paolo. 

‘ r^IlCHELE, 

‘ You  wish  to  make  your  son  a priest  ? Bravo  ! ! Very  good  ! ! ! 
What  a worthy  priest  is  there  ! ! ! ! Set  him  to  work  in  the  fields,  and 
let  him  prove  the  stuff  of  which  he  is  made.  Truly  I say  unto  you, 
Michele,  that  my  greatest  regret  is  to  see  that  poor  theologian  reduced  to 
such  a sorry  case.  . . . 

‘ Look  to  this  matter  and  at  once  strip  the  cassock  off  the  back  of 
that  demon  son  of  yours ; otherwise  you  will  see  how  many  other  bad 
effects  will  follow  from  your  course. 

‘ A true  friend  of  yours, 

‘ N.  N.’  , 

The  day  after  the  assault  Conte  stammered,  was  rigid  and  torpid, 
while  there  was  a feeling  of  weight  in  his  right  limbs.  Shortly  afterwards 
he  completely  lost  consciousness,  and  had  incomplete  hemiplegia  on 
the  right  side,  as  there  was  no  trace  of  facial  paralysis.  His  tongue 
was  shrunken  in  the  mouth.  The  paralysis  was  flaccid. 

Conte  remained  in  that  condition  for  about  four  days,  and  when  he 
began  to  recover  consciousness,  his  tongue  was  so  shrunken  and  so  much 
contracted  that  he  could  not  put  it  out  of  his  mouth.  There  was  hemi- 
anaesthesia  on  the  same  side  as  the  paralysis. 

On  the  second  day  following  the  attack  fever  developed  (nothing 
is  known  of  his  temperature  on  the  first  day),  reached  a maximum  of 
39°  C.,  and  lasted  for  seven  or  eight  days. 

Thirty-five  days  elapsed  before  he  recovered  the  power  of  motion  in 
the  lower  limb,  and  the  upper  limb  recovered  only  subsequently  to  that. 
In  fifty  days  the  hemiplegia  was  almost  completely  cured,  so  that  the 
patient  could  use  his  right  upper  limb,  although  it  was  still  very  weak. 
Two  months  after  the  attack  recovery  was  perfect. 

About  a fortnight  before  our  interrogatory  Conte  suffered  a new  attack 
of  an  apoplectic  nature,  with  clouding  of  the  consciousness,  heightened 
colour  in  the  face,  and  transient  hemiplegia  on  the  right  side.  The 
medical  attendants  resorted  to  bleeding  at  the  nape  of  the  neck  and  at 
the  mastoid  processes,  and  the  patient  was  very  soon  restored  through 
this  treatment. 

Paolo  Conte  is  a young  man  of  twenty-two  or  twenty- three  years  of  age, 
well  developed,  with  limbs  and  trunk  in  good  proportion.  In  his  bearing 
he  is  somewhat  of  a dandy,  being,  moreover,  of  a slender  build.  He  has 
a thick  growth  of  hair,  blonde  and  tending  to  albino.  The  eyes  are  light 
blue  a.nd  shifty,  while  his  look  is  not  particularly  intelligent,  being  rather 
languid.  The  skin  is  extremely  white,  with  faint  spots  of  red.  His 
lips  are  bright  red,  and  wear  an  almost  constant  smile.  He  is  not  alto- 
gether unprepossessing,  but  he  is  not  interesting.  He  has  no  hair  on 
the  body  except  on  the  pubis.  His  beard  is  sparse  and  only  nascent. 
He  bears  no  anthropological  signs  of  degeneracy.  The  circumference 
of  his  head  is  56  centimetres. 

Ah  the  organs  are  sound,  and  perform  their  functions  normally. 

I make  particular  mention  of  the  vascular  system,  which  presents  no 
pathological  features.  The  genitals  are  regularly  developed,  but,  on 
Conte’s  own  confession,  they  have  been  subjugated  by  his  ‘ will,’  against 
which  they  have  never  rebelled,  not  even  in  sleep. 

The  cutaneous  sensibility  is  ever}rwhere  well  preserved,  and  is  even 
exquisite  in  proportion  to  the  delicacy  of  the  skin.  There  is  no  disorder 
of  the  special  senses.  The  field  of  vision  is  normal,  also  the  power  of 

35 


546 


PSYCHIATRY 


vision  in  both  eyes.  Conte  also  recognises  all  colours  very  easily,  as 
well  as  their  different  shades. 

The  superficial  reflexes  are  quite  perfect.  The  patellar  reflex  is 
normal,  but  the  tendinous  reflex  of  each  hand  is  notably  exaggerated. 

There  have  not  been  any  true  psychic  disturbances,  excepting,  of 
course,  the  catalepsy  that  he  suffered  in  the  Bishop’s  house,  and  the 
attack  of  apoplexy.  Conte  is  of  average  intelligence,  with  a mediocre 
degree  of  culture  for  a priest.  ‘ His  faculty  of  memory  suffers  lapses,  and 
he  often  makes  errors,  due  to  the  failure  of  this  faculty,  when  he  is  asked 
to  give  dates  and  events  precisely.  His  will,  if  we  are  to  judge  from  the 
fact  that  he  became  subiect  to  Fusco,  whose  instructions  he  followed 
blindly,  cannot  be  considered  to  be  developed  to  that  degree  we  look 
for  in  a normal  man. 

Conte’s  sentiments  are  all  weak,  and  in  their  mechanism  the  idea  of 
his  own  personality  plays  an  important  part.  At  the  seminary  a trivial 
offence,  such  as  often  occurs  among  youths,  was  sufficient  to  make  him 
break  into  convulsions  for  the  first  time,  and  that  ‘ offence  to  his  amour 
propre  ’ tormented  his  consciousness  for  many  days.  He  shows  great 
affective  excitability  and  highly  passional  states. 

Not  only  does  he  love  his  family,  but  he  is  unspeakably  delighted  with 
the  care  and  attention  that  his  parents  and  brothers  heap  upon  him,  and 
he  is  intensely  pleased  at  the  pity  that  he  inspires  in  others,  taking  up 
the  attitude  of  a victim  of  the  villainy  of  this  world  and  of  the  will  of 
God  ; but  when  his  mother,  wearied  with  the  struggles  of  many  years, 
was  alone  in  her  house  weeping  over  the  hard  fate  that  had  befallen  her 
and  the  misfortune  of  the  son,  upon  whose  ecclesiastical  career  she  had 
fixed  her  mind  in  hope,  he,  as  a sufferer  from  paraplegia,  was  going  about 
the  streets  of  Castellamare  on  a hand-cart  drawn  by  a donkey,  looking  = 
out  for  his  friends  and  amusing  himself.  ; 

Even  although  he  had  been  educated  in  a seminary,  a school  of  ; 
religion  and  faith,  and  though  neither  from  his  own  intelligence  nor 
frorn  his  surroundings  could  he  derive  other  sentiments  to  replace  those  ’ 
inspired  by  the  Catholic  school,  yet  one  fine  day,  simply  because  he  had  \ 
been  offended  by  his  Bishop,  he  repudiated  the  Catholic  religion,  and 
spoke  with  sarcasm  of  the  miracle  worked  by  Pius  IX.  ; 

In  the  public  hall  of  the  tribunal  he  pointed  out  ironically,  and  with 
an  air  of  ill-disguised  disdain,  the  relics  of  Pius  IX.  that  had  been  pre-  ; 
sented  to  him  by  the  Cardinals  and  by  Pope  Peed  at  Rome.  During  • 
our  examination  he  made  very  unseemly  remarks  about  his  enemies  ) 
and  the  Catholic  party.  ' i 

He  is  notoriously  vain.  When  the  case  was  being  heard  in  the  public  ; 
courts  he  showed  himself  quite  pleased,  smiling  with  an  amused  air,  as  if  i 
the  whole  matter  did  not  concern  him  in  the  very  slightest.  The  interest  < 
taken  by  the  public  in  his  case  exercised  an  indescribable  fascination  on 
his  mind,  and  nothing  could  move  him  or  make  any  impression  on  him.  On 
the  day  when  it  became  my  duty  to  state  in  public  my  opinion  of  his  mental 
condition,  and  when  I had  to  emphasize  his  tendency  to  lie,  to  bring 
false  accusations  against  those  whom  he  hated,  to  make  a drama  of  every 
occurrence,  to  pretend  that  he  had  been  attacked,  to  write  anonymous 
letters,  to  wound  himself  and  accuse  others  of  the  deed,  to  implicate 
honest  people  in  grotesque  or  scandalous  judicial  cases,  there  he  stood  y 
opposite  me,  always  smiling  and  quite  undisturbed.  To  a gentleman,  " 
probably  a journalist,  who  asked  him  for  a photograph,  he  replied  with 
great  satisfaction  : ‘ Yes,  I shall  give  you  two— -one  showing  myself  in 
civil  garb  as  I am  now,  the  other  taken  when  I wore  the  habit  of  the 
priesthood.’  He  made  a theatrical  display  of  his  malady.  He  recounted 
the  various  phases  of  it  to  everybody,  not  like  one  who  suffers  or  has 
suffered  a great  deal,  but  with  an  air  of  satisfaction. 


: 


HYSTERICAL  INSANITY 


547 


Two  months  after  the  trial  had  taken  place,  and  all  those  whom  he 
had  accused  were  condemned  (for  my  opinion  that  he  was  feigning  was 
not  accepted  by  the  judge),  he  awoke  as  if  from  a dream,  recognised  all 
the  evil  that  he  had  done,  and  came  to  me,  declaring  : ‘ I do  not  know 
how  or  why  I have  performed  this  comedy ; I invented  the  whole  busi- 
ness ; but  now  it  seems  to  me  as  if  I had  been  in  a dream,  and  had  obeyed 
some  superior  force.  Only  now  does  the  reality  of  my  existence  appear 
plain  to  me.’ 


Here  is  a case  of  hysterical  delinquency,  following  upon  a true 
duplication  of  the  personality  : 

OssERyATiON  X. — On  June  21,  1896,  the  Ouestor  of  Naples  laid 
before  the  Public  Prosecutor  a case  of  fraud  committed  by  Madame  S., 
as  alleged  by  the  victim.  Car.  A.  The  latter  was  in  the  omnibus  of  the 
Hotel  Pagano,  in  the  island  of  Capri,  when  she  made  the  acquaintance 
of  Madame  S.,  who  declared  herself  to  be  Sibilla  R.,  of  American  birth, 
and  belonging  to  Canada. 

‘ She  won  my  friendship,’  said  A.,  ‘ with  her  very  nice  manners,  and 
got  me  to  believe  that  she  was  betrothed  to  a German  gentleman  attached 
to  the  German  Embassy.’ 

Meanwhile  A.  went  to  Portici,  and  a few  days  afterwards,  on  June  ii, 
she  received  a visit  from  S.,  a second  visit  being  made  on  the  i6th.  On 
that  last  occasion,  S.  said  that  it  was  her  birthday  and  she  had  been  the 
victim  of  a great  misfortune,  for  her  pocket-book,  containing  300  lire, 
a cheque  on  Florence,  and  a portrait  of  her  betrothed,  had  been  stolen 
from  her  in  Naples,  so  that  she  was  without  resources.  She  added  that 
she  had  been  to  the  office  of  the  Questor  to  lodge  a complaint. 

A.  believed  the  tale,  and  out  of  compassion  gave  her  a deposit  receipt 
for  500  lire,  so  that  she  might  cash  it  at  the  Casa  Meuricoffre  and  bring 
the  money  to  her.  She  intended  a part  of  that  sum  to  meet  the  needs 
of  her  friend. 

After  awaiting  in  vain  for  some  days  the  delivery  of  the  money,  A. 
went  first  to  the  Casa  Meuricoffre,  and,  having  ascertained  that  the 
deposit  receipt  was  quite  in  order,  she  went  to  the  Hotel  de  Russie,  where 
she  learned  that  S.  had  removed  to  the  Hotel  Continental.  At  the  last 
address  she  ascertained  that  S.  had  left  for  Tunis,  and  that  she  had  stayed 
in  that  hotel  under  the  name  of  O.  B.  Meanwhile,  when  the  Questor 
of  Naples  was  transmitting  A.’s  complaint  to  the  Public  Prosecutor, 
it  was  learned  from  other  quarters  that  the  soi-disant  Sibilfa  R.  B., 
under  the  name  of  Silvia  B.,  had  been  wanted  by  the  police  of  Viareggio 
ever  since  the  month  of  March  past  for  fraud  and  false  statements  whereby 
she  had  got  the  better  of  A.  T.,  banker.  The  Prefect  of  Como  also 
telegraphed  : 

‘ I request  you  to  try  to  arrest  the  famous  swindler,  S.  L.  S.,  aged 
forty-four,  from  London.  Middle  height,  elegant  figure,  always  dressed 
in  dark  colours  ; dark  brunette,  with  marks  of  pimples  on  the  lower  part 
of  the  face.  Black  hair,  with  artificial  curls  ; no  earrings.  She  frequents 
the  principal  hotels,  always  changing  her  name.  She  commits  fraud 
by  means  of  cheques  that  she  extracts  from  her  fellow-countrymen,  with 
whom  she  gets  on  intimate  terms.  Last  known  to  be  at  Palermo,  where 
she  said  that  she  was  leaving  for  Rome,  Milan,  and  Pallanza.’ 

Further  than  that,  on  May  4,  1896,  the  Questor  of  Rome  sent  on  a 
note  in  which  he  said  that  the  soi-disant  R.  von  B.,  against  whom  a 
warrant  for  arrest  had  been  issued  by  the  examining  magistrate  there, 
was  considered  by  the  German  police  to  be  a particularly  dangerous  thief, 
and  that  she  had  finally  been  identified  as  S.  L.  S.  S.,  or  the  widow  B., 

35—2 


54^ 


PSYCHIA  TRY 


born  at  London  in  1852.  By  order  of  the  Council  of  Frankfurt-on- the-  ? 
Main,  dated  October  9,  1894,  she  had  been  conhned  in  an  asylum  as  an  | 
incurable  and  dangerous  lunatic,  and  it  would  appear  that  she  had  ! 
escaped  from  that  asylum  some  time  previously. 

When  the  accused  was  examined  at  Palermo  she  repeated  exactly 
what  she  had  told  us,  and  what  is  reported  in  the  clinical  history  of  the 
case.  She  admitted  that  she  had  assumed  the  surname  B.,  not  in  order 
to  conceal  her  own  name,  but  simply  because  that  was  a pseudonym  that 
she  had  used  for  various  literary  publications  printed  in  American 
papers  ; and  she  had  a good  reason  for  not  giving  her  proper  name,  for 
she  had  escaped  from  an  asylum,  and  was  afraid  of  being  taken  back 
there. 

She  admitted  that  a post-card  written  to  A.,  under  the  name  of  B., 
was  her  production,  and  she  added  that  if  she  had  done  a dishonest  actiori  i 
she  would  not  have  written  to  her  friend  at  all.  | 

Moreover,  in  a report  made  by  the  Questor  of  Naples  to  the  Public  | 
Prosecutor,  dated  September  17,  1896,  it  is  said  : ‘ No  sooner  had  she  j 
been  taken  to  Palermo  than  she  confessed  to  some  acts  of  fraud  com-  | 
mitted  there  and  at  Cernobbio,  but  she  stoutly  denied  having  defrauded  ‘ 
A.  of  500  lire.  It  is  known  that  the  accused  had  made  a round  of  the  ' 
principal  cities  of  Italy,  continually  changing  her  name,  and  committing  j 
frauds  everywhere.  The  chief  inspector  of  this  office  of  Ouestorship  j 
took  up  the  search  for  her  in  person,  and  yesterday  S.  was  arrested  at  : 
Syracuse.’  i 

She  had  been  convicted  of  fraud  in  France  and  in  England.  In  ' 
France  she  was  once  shut  up  in  an  asylum  for  kleptomania.  ,j 

The  foregoing  is  a summary  of  her  life  for  the  last  few  years.  ' 

She  was  brought  to  the  psychiatric  clinique  under  my  direction  on 
November  27,  1896,  under  the  name  of  S.  Luisa  Susanna  fu  Guglielmo,  1 
of  London,  aged  forty-four,  widow,  Catholic.  !| 

I proceed  to  relate  everything  that  I have  been  able  to  learn  about 
this  woman. 

In  her  family  there  had  been  a remarkable  number  of  sufferers  from 
diseases  of  the  chest,  or  from  tuberculosis.  Her  father  died  of  phthisis  ! 
at  the  age  of  fifty.  He  had  attained  a high  rank  in  the  British  army,  I 
had  fought  valiantly  in  the  Crimea,  and  was  for  some  time  in  India  and  ^ 
in  Afghanistan.  Her  mother  was  a Frenchwoman,  very  nervous,  and  a .j 
sufferer  from  hemicrania.  A maternal  aunt,  a Superior  of  the  Sisters  of ; 
Charity  in  Italy,  had  also  been  neuropathic.  One  brother  was  drowned  I 
at  sea,  while  another  died  of  tuberculosis  ; the  latter  was  at  one  time  in-i 
Parliament,  and  wrote  several  books.  Three  other  brothers  died  inij 
infancy,  of  ordinary  diseases.  Two  sisters  have  chosen  to  remain 
unmarried  because  of  ill-health  and  chest  troubles.  The  accused  has'* 
had  scarlatina,  measles,  and  latterly  rheumatic  fever.  For  a certain 
t me  she  was  anaemic  to  a marked  degree.  As  far  back  as  her  recollection 
goes  she  declares  that  she  was  almost  constantly  tormented  with  hemi- 
crania, sometimes  more  and  sometimes  less  severe,  but  always  on  the  . 
right  side.  To  get  rid  of  this  she  tried  an  endless  number  of  remedies, 
but  always  in  vain.  She  remembers  that  at  Frankfurt  she  took  anti- 
p\Tine,  micranine,  phenacetin  and  morphine,  but  always  without  any 
result. 

She  menstruated  at  seventeen,  married  at  twenty-one,  and  has  had 
one  son,  who,  like  herself,  suffers  from  hemicrania. 

She  has  passed  a good  number  of  the  years  of  her  life  in  different  1 
asylums  in  England,  America,  and  Germany. 

Her  first  nervous  troubles  go  back  to  1876  or  1877.  What  their  1 
nature  was  I cannot  clearly  say,  but  it  is  certain  that  her  medical  advisers  ' 
told  her  to  go  to  Spa.  While  there  she  received  letters  from  her  husband 


HYSTERICAL  INSANITY 


549 


every  day,  but  one  day  she  became  convinced  that  she  had  never 
heard  a word  frcm  him,  and  she  telegraphed  to  him  to  come  to  her 
immediately. 

In  1882  for  the  first  time  she  entered  an  asylum  in  London.  She 
was  under  the  impression  that  she  had  received  a letter  announcing  the 
death  of  her  sister,  and  nothing  could  convince  her  to  the  contrary.  She 
put  on  mourning,  and  commenced  to  do  hundreds  of  strange  things. 
Among  other  whims  she  had  an  excessive  and  irrational  fear  of  filth,  and 
would  hardly  touch  anything  at  all.  She  was  continually  having  her 
furniture  changed,  and  she  insisted  that  it  should  be  dusted  every 
minute. 

She  left  the  asylum  after  a stay  of  three  months,  in  order  to  go  to 
America  along  with  her  husband,  who  had  business  to  transact  there. 
Shortly  afterwards,  in  1883,  she  was  admitted  into  one  of  the  State 
asylums,  where  she  remained  for  eighteen  months.  She  does  not 
remember  what  it  was  that  caused  this  new  detention,  and  she  recollects 
nothing  of  what  she  did  or  what  happened  to  her  during  that  time. 

A third  time  she  was  received  into  an  asylum  at  New  York,  where 
she  remained  from  1885  to  1889.  It  seems  that  there  she  was  confined 
to  bed  for  two  years,  1887  to  1889,  on  account  of  a surgical  affection  of  the 
genital  organs,  for  which  she  was  operated  upon.  For  a long  time  she 
would  take  no  food  except  a very  small  quantity  of  milk,  and  the  weight 
of  her  body  fell  from  136  to  66  pounds.  She  remembers  that  during  her 
stay  in  that  asylum  she  was  fed  by  force,  and  that  she  refused  nourish- 
ment for  no  other  reason  than  lack  of  appetite.  According  to  her  story. 
Dr.  T.,  the  medical  superintendent  of  that  asylum,  tried  to  hypnotize 
her  in  order  to  cure  her  of  anorexia.  To  that  attempt,  which  had  no 
curative  result,  she  attributes  a great  part  of  the  troubles  that  have  since 
afflicted  her.  In  June,  1889,  she  was  transferred  to  another  asylum. 

In  April,  1890,  she  regained  her  liberty  and  returned  to  Europe,  going 
to  Berlin.  She  was  well,  and  lived  with  her  husband  until  1893  ; then 
suddenly  she  was  seized  with  hallucinatory  disturbances.  At  that 
time  she  was  still  under  the  influence  of  a great  impression  produced 
upon  her  through  reading,  whilst  in  the  New  York  asylum,  a book  by 
Stevenson,  in  which  there  is  a story  of  the  transformation  of  one  person 
into  another,  and  accounts  of  many  other  strange  phenomena.  It  is 
quite  certain  that  one  day  she  thought  she  saw  her  husband  hanged, 
with  a noose  around  his  neck.  She  was  in  great  despair,  and  soon  after- 
wards left  for  England  to  join  her  sisters.  There  she  was  admitted  to 
one  of  the  London  asylums,  where  she  remained  six  months,  until  October, 

1893. 

When  she  recovered  her  liberty  she  learned  of  the  death  of  her  husband. 
Then  commenced  a new  Odyssey  for  our  patient,  not  from  asylum  to 
asylum  this  time,  but  from  countr}^  to  country.  Between  October,  1893, 
and  June,  1894,  she  visited  more  than  fifty  towns.  She  constantly 
heard  a voice  speaking  in  her  right  ear,  ordering  her  to  go  here  and  there, 
and  that  voice  she  had  perforce  to  obey.  ' It  is  Dr.  T.,’  she  asserted, 
‘ who  is  amusing  himself  by  tormenting  me  in  this  way'.’ 

Finally,  about  July  or  August,  1894,  she  reached  Frankfurt,  and  was 
confined  in  the  asylum  there,  where  she  remained  until  August,  1895. 
At  that  time  she  was  absolutely  convinced  that  she  had  contracted  a 
second  marriage  with  a certain  Enrico  Bertrand,  altogether  an  imaginary 
person.  She  cannot  say  how  that  conviction  arose,  but  it  is  certain  that 
she  was  so  sure  of  it  that  in  the  asylum  she  gave  the  name  of  her  pre- 
sumed husband.  She  still  remembers  that  one  cold  day  in  December, 

1894,  when  she  was  admiring  the  new-fallen  snow,  she  heard  the  customary 
voice,  which  this  time  b.ade  her  hang  herself.  She  was  carrying  out  the 
order  when  a thunderbolt  fell  (this  is  an  actual  fact,  as  I had  afterwards 


550 


PSYCHIATRY 


occasion  to  ascertain),  and  she  thought  that  she  had  a vision  of  the 
Madonna.  She  swooned,  and  was  unconscious  for  more  than  two  hours. 

In  the  asylum  at  Frankfurt  she  won  the  love  of  all,  and  gained  so 
much  sympathy  from  the  superintendent  and  his  wife  that  she  was 
allowed  very  great  liberty.  One  fine  day  she  took  advantage  of  that 
and  made  her  escape.  Then  she  resumed  her  wanderings,  always  per- 
secuted by  the  voice  that  continually  ordered  her  to  go  hither  and 
thither.  One  day,  at  the  end  of  September,  1896,  when  she  was  in  Palermo 
she  felt  a very  curious  sensation,  starting  at  the  root  of  the  nose  and 
running  to  the  right  temple,  accompanied,  according  to  her  account, 
by  bleeding.  From  that  time  her  hemicrania  and  her  hallucinations 
disappeared. 

Finally  she  reached  Naples  about  October  4,  1896.  While  there, 
one  day  she  lost  in. a carriage  her  pocket-book,  containing  a very  con- 
siderable sum.  In  the  evening,  having  gone  to  dine  with  a lady  friend, 
she  was  questioned  as  to  the  reason  of  her  dejection,  and  she  related  all 
that  had  occurred.  Thereafter  she  accepted  the  sum  of  500  lire  which 
that  friend  was  good  enough  to  offer  her  by  way  of  loan.  To  her  un- 
bounded astonishment,  she  learned  one  day  that  she  had  been  accused 
of  fraud,  and  she  found  herself  in  the  prison  of  Santa  Maria  Agnone. 

Could  this  be  another  version  of  the  story  that  formed  an  accusation 
against  her  ? It  will  be  seen  that  it  differs  very  markedly  from  the 
account  given  by  the  Questor  and  from  the  complaint  lodged  by 
Madame  A. 

From  her  childhood  our  patient  has  occupied  her  mind  with  serious 
study,  finally  graduating  with  the  degree  B.A.,  within  a few  months  of 
obtaining  which  she  married.  In  addition  to  mastery  of  the  English 
language,  she  knows  German  very  well,  French  well,  and  Italian  and 
Spanish  moderately.  She  has  learned  a little  Latin  and  Greek,  and  the 
elements  of  the  various  sciences.  She  knows  music  also,  and  she  is  a 
player  of  the  pianoforte.  She  writes  shorthand. 

In  1883,  while  in  America,  she  commenced  writing  some  pieces  of 
poetry  and  articles  on  the  woman’s  question.  She  was  then  in  an 
asylum,  and  the  manager  of  the  Utica  Herald,  who  had  a sister  an  inmate 
there,  got  these  into  his  hands  and  published  them.  Thereafter,  in  the 
year  1892,  she  published  two  novels.  The  first  of  these  is  rather  a study 
on  the  education  of  children  than  a novel,  the  idea  that  the  author 
wishes  to  develop  being  that  the  first  duty  of  parents  is  to  attend  them- 
selves to  the  upbringing  of  their  children.  It  treats  of  parents  who 
think  only  of  science  and  philosophy  ; of  a mother  who,  in  order  to 
imitate  her  husband  in  his  study  of  those  subjects,  which  was  certainl}^ 
out  of  place  where  there  were  children,  entrusted  everything  to  a governess^ 
who,  however,  was  very  good  and  well  educated. 

In  the  second  story  the  author  wishes  to  prove  that  it  is  the  duty  of 
every  woman  to  extend  a pitying  hand  to  her  lost  sisters.  She  is  at 
present  writing  a new  work,  in  which  she  intends  to  deal  with  life  in 
asylums. 

It  is  difficult  to  affirm  whether  these  two  books,  which  she  claims  to 
have  written  under  a pseudonym,  are  really  her  work.  The  style  appears 
to  me  to  be  hers,  and  no  one  can  deny  that  she  has  the  ability  to  write 
them. 

I thought  well  to  apply  to  the  superintendents  of  the  asylums  of  which 
she  had  been  an  inmate  in  order  to  get  a full  account  of  her,  and  the 
information  thus  collected  has  been  compared  at  all  points  with  the  story 
that  she  herself  told  me. 

I a])plied  to  the  superintendents  of  the  London  asylums,  requesting 
information  about  Madame  S.  They  replied  that  they  knew  nothing 
of  her,  and  that  was  confirmed  by  a polite  letter  sent  me  by  the  chairman 


HYSTERICAL  INSANITY 


551 


of  the  Lunacy  Board.  When  I reproved  her  for  giving  me  false  informa- 
tion she  showed  no  discomposure,  but  said  that  I had  made  a mistake 
in  asking  about  her  under  her  paternal  name  S.,  because  in  the  London 
Asylums  she  had  been  received  under  the  name  of  her  husband  B.  I 
wrote  again,  and  received  precise,  although  short,  notes,  in  a letter  dated 
April  4,  1897,  in  which  I was  assured  that  Madame  B.  had  been  in  prison 
and  in  asylums  in  America  ; that  she  had  presented  phenomena  of 
depression,  auditory  hallucinations,  and  grave  menorrhoea.  All  that 
arose  upon  a basis  of  hysteria. 

The  letter  that  Dr.  S.,  Director  of  the  Frankfurt  Asylum,  kindly  sent 
me  was  much  more  detailed.  He  states  that  Madame  Luisa  S.  Sybilla  Be., 
n^e  S.,  widow  B.,  was  received  into  the  Frankfurt  Asylum  on  August  31, 
1894. 

Before  her  admittance  to  the  asylum  she  had  been  in  prison  on  sus- 
picion of  a great  robbery  of  jewels.  Inquiries  made  by  Dr.  S.  brought 
to  light  the  fact  that  the  name  of  Be.  was  false  ; that  she  was  simply 
Madame  B.  ; that  a sister  of  hers  had  committed  suicide  ; that  in  1883 
she  had  committed  a theft,  and  had  been  declared  insane  by  experts  ; 
that  she  had  been  an  inmate  of  a certain  United  States  asylum  from 
May  to  October,  1883  ; of  one  New  York  asylum  from  September  17, 
1885,  to  June  27,  1889  ; of  another  from  June  27,  1889,  for  a period 
of  unknown  duration  ; and  from  October  13,  1893,  she  was  again  an 
inmate  of  a London  asylum.  From  information  that  Dr.  S.  had  col- 
lected from  the  superintendents  of  those  institutions,  it  is  certain  that 
Madame  B.  was  received  into  them  with  phenomena  of  pronounced 
morphinism,  and  suffering  from  affective  states  of  depression,  with 
anguish  and  a tendency  to  suicide. 

There  is  nothing  notable  in  the  way  of  degenerative  anthropological 
marks,  except  that  the  lobules  of  the  ears  are  adherent,  and  that  the 
upper  and  lower  teeth  are  prognathous.  An  examination  of  the  organs 
showed  nothing  noteworthy. 

She  still  menstruates,  and  sometimes  the  menstruation  is  of  abnormally 
long  duration.  She  suffers  great  pain  in  the  hypogastric  region  (peri- 
metritis), and  for  some  time  after  menstruation  ceases  she  has  an  abundant 
flux  from  the  uterus  and  the  vagina. 

Her  general  nutrition  has  become  rather  defective.  The  weight  of 
the  body  on  January  8 was  99  pounds.  There  is  marked  hypersesthesia, 
also  anaesthesia. 

There  is  hypersensibility  to  painful  stimuli,  even  though  they  be 
slight. 

All  movements,  even  delicate  ones,  can  be  made  with  the  eyes  shut. 
She  can  detect  more  minute  differences  in  weight  than  the  average 
individual. 

She  has  exact  perception  of  the  four  fundamental  tastes,  both  on  the 
front  half  and  on  the  back  half  of  the  tongue. 

Her  power  of  vision  is  normal,  and  her  sense  of  colour  is  also  normal. 
The  field  of  vision  of  both  eyes  is  restricted. 

She  has  suffered  for  a long  time  from  hemicrania.  At  present 
from  time  to  time  she  complains  of  pain  limited  to  the  upper  part  of 
the  head.  During  atmospheric  changes  she  is  sometimes  more  melancholy, 
but  at  other  times  more  excitable  and  irritable.  Her  kinaesthesis  is- 
usually  depressed.  The  cutaneous  reflexes  are  normal.  The  vessels 
of  the  head  are  very  prominent. 

Since  she  has  been  received  into  the  asylum  we  have  never  been  able 
to  discover  in  this  lady  any  anomaly  at  all  that  is  worthy  of  considera- 
tion, or  that  possesses  any  semeiotic  value  for  the  diagnosis  of  an 
abnormal  psychic  condition. 

She  was  perfectly  conscious  of  her  state,  of  her  new  conditions  of 


552 


PSYCHIATRY 


life,  and  of  her  new  relations.  From  dhe  first  moment  she  fully  under- 
stood her  position  as  an  inmate  of  an  asylum,  and  although  she  did  not 
like  It,  she  adapted  herself  to  the  discipline  of  the  establishment  and  to 
the  monotony  of  the  life  that  is  led  there.  She  was  not  accustomed  to 
the  food  that  was  given  to  the  inmates  in  general  of  the  establishment 
and  as  we  have  no  boarding  arrangements  at  Sales,  she  suffered  much’ 
particularly  for  the  first  few  days,  on  account  of  the  food,  which  frorn 
previous  habits,  was  certainly  not  suitable  for  her  stomach. 

However,  she  besought  the  matron  so  nicely,  and  she  was  able  to 
gam  her  liking  to  such  a degree,  that  the  latter  consented  to  allow  her 
to  eat  at  her  table.  That  was  done  with  my  permission,  while  the 
matron  also  had  some  more  delicate  food  prepared  for  her. 

Nothing  has  escaped  her  from  the  first  day  of  her  admittance  into  the 
climque  neither  positions  nor  names  of  the  nurses,  nor  the  doctors 
nor  their  attitude  and  their  bearing  towards  herself  and  the  other  patients  ; 
nor  the  psychic  states  and  the  tendencies  of  the  inmates  with  whom  she 
was  obliged  to  remain  in  contact  for  some  considerable  time.  As  she 
found  some  difficulty  in  expressing  her  ideas  to  others,  particularly  to 
me  nurses  and  to  the  matron — for  it  was  not  possible  to  converse  in 
hrench  or  English  except  with  the  medical  superintendent  and  one  or 
two  of  the  doctors— in  a little  time  she  learned  both  Italian  and  the 
Neapolitan  dialect  sufficiently  well  to  answer  her  needs,  in  so  far  as  the 
immediate  requirements  of  everyday  life  are  concerned. 

Her  speech  is  always  logical.  She  is  never  caught  in  a contradiction, 
m any  strangeness,  or  in  incoherency.  She  judges  men,  things  and 
events  as  a woman  of  culture  and  astuteness  might  judge  them— with 
equity  and  with  keen  acumen.  She  never  makes  gross  mistakes. 

There  is  no  need  to  direct  her  attention  to  things  and  acts 
for  nothing  escapes  her  wide  perspicacity. 

Her  memory  is  ready  and  faithful.  To  prove  that,  it  is  sufficient  to 
state  that  she  can  relate,  in  due  order  and  with  proper  connection,  all 
the  episodes  of  her  life.  It  was  she  who  gave  me  the  names  of  the  asylums 
of  which  she  had  been  an  inmate,  of  the  cities  in  which  they  were  situ- 
ated  of  the  doctors  at  the  head  of  them,  and  the  dates  of  her  admission 
and  dismissal.  It  was  on  her  indications  that  I wrote  and  got  answers 
from  the  various  superintendents  of  the  asylums  of  which  she  had  been 
an  inmate.  She  had  forgotten  nothing — none  of  the  episodes  nor  even 
of  the  anecdotes  of  the  whole  of  her  normal  life,  and  that  applies  both 
to  the  most  remote  as  well  as  to  the  most  recent  occurrences. 

A proof  of  her  intelligence  is  to  be  found  in  the  written  document 
that  I invited  her  to  give  me,  containing  a succinct  history  of  her  life. 
She  wrote  the  seven  sheets  in  a little  over  two  hours,  without  ever  repeat- 
ing herself  or  placing  a single  word  wrongly  ; and  she  was  wonderfully 
accurate  as  to  names  of  men  and  of  places,  as  to  dates  and  events. 

Her  affections  and  sentiments  showed  absolutely  no  trace  of  anything 
abnormal,  except  emotiveness.  On  the  other  hand,  this  lady  shows 
quite  uncommon  fineness  of  breeding. 

Loud  speech,  roughness  on  the  part  of  any  one  of  our  female  hospital 
attendants,  who  are  recruited  from  the  lowest  social  strata,  or  ungentle 
treatment  of  any  of  her  companions  in  misfortune,  however  unruly  and 
aggressive  the  latter  may  have  been,  produces  in  her  real  suffering,  and 
she  does  not  hide  her  resentment  either  from  the  doctor  in  charge,  from 
myself  or  from  the  matron.  Suffering  in  others  touches  and  moves 
her.  She  has  often  reproved,  in  the  most  ladylike  fashion  imaginable, 
a hospital  attendant  for  some  rudeness  offered  to  herself  or  to  one  of  the 
other  inmates.  One  day  she  heard  the  doctor  of  her  section,  to  whom 
she  was  giving  lessons  in  English  by  way  of  recreation,  make  use  of  a 
phrase  that  she  considered  not  quite  proper,  and  she  stopped  all  inter- 


HYSTERICAL  INSANITY 


553 


course  with  him,  even  the  English  lessons.  That  was  done  not  from 
pride  but  from  the  disgust  that  an  action  that  appears  to  her  discourteous, 
whether  directed  against  herself  or  others,  always  produces  in  her.  I 
got  the  matron  to  take  her  into  her  confidence,  and  I allowed  the  patient 
to  eat  at  her  table  in  order  to  put  her  to  the  test,  and  she  has  always 
behaved  with  the  greatest  delicacy.  She  has  never  lied,  nor  has  she  ever 
repeated  what  she  has  noticed  with  the  intention  of  making  mischief, 
and  she  has  never  appropriated  anything  that  did  not  belong  to  her. 
She  is  always  affable,  always  anxious  about  the  misfortunes  of  others, 
always  willing  to  do  something. 

She  is  respectful,  correct,  and  disciplined.  Certainly  she  has  not 
adapted  herself  to  the  exigencies  of  asylum  life,  but  she  ha,  suffered 
with  resignation,  and  only  just  lately,  when  she  has  been  weary  of 
suffering  and  uncertain  as  to  her  fate,  has  she  sometimes  broken  out 
into  complaints.  At  other  times  she  has  assured  me  that  she  would 
prefer  to  end  her  life  rather  than  continue  in  this  way  for  a long  time. 
However,  these  outbreaks  have  no  pathological  character  ; on  the 
contrary,  there  is  a sound  reason  for  them. 

She  passes  her  time  in  reading,  sometimes  in  writing,  and  sometimes 
in  domestic  work.  Very  rarely  is  she  to  be  found  idle. 

To  sum  up  the  case,  we  have  found  on  the  somatic  side  a figure  of 
subdegenerative  type,  especially  if  she  be  contrasted  with  the  consti- 
tution of  the  Anglo-Saxon  woman.  On  the  intellectual  and  moral  side, 
when  in  her  normal  state,  she  is  a woman  of  sound  culture  and  of  strict 
upbringing.  Her  sentiments  are  fine,  delicate,  social,  humane.  She 
is  free  from  the  feminine  love  of  tattle,  and  is  unstained  by  the  porno- 
graphic sense  of  words  and  by  ambiguous  behaviour.  On  the  other 
hand,  her  emotiveness  is  truly  exaggerated  and  diseased.  She  easily 
represents  to  herself  ideas  and  images  as  truths,  while  there  is  an  exchange 
of  thought  for  reality  and  real  duplication  of  the  personality,  with  change 
of  disposition,  tendencies  and  conduct — a true  psychic  dispolarization. 
In  these  states  of  duplication,  some  of  which  are  represented  by  gaps  in 
her  history,  she  committed  the  offences  with  which  she  has  been  charged. 

Hysterical  Stupor,  with  Stereotyped  Poses,  of  Sexual  or 
Hypochondriacal  Nature. 

In  the  cases  belonging  to  this  group  the  field  of  intellect  is  closed, 
and  the  affective  sphere  is  almost  entirely  obliterated.  Past  emotions, 
of  greater  or  less  intensity,  and  usually  excited  by  sexual  episodes, 
bring  about  the  attitude  associated  with  those  episodes.  There  is  a 
species  of  mental  catalepsy,  during  which  there  is  vividly  recalled 
the  infantile  age  at  which  occurred  those  events  that  furnished  a 
new  .spiritual  product  capable  of  overthrowing  and  arresting  all 
movement  in  the  mental  field.  During  this  condition  of  mental 
catalepsy  the  age  at  which  the  episode  and  the  pose  occurred  are 
remodelled,  even  though  it  be  many  years  later,  and  some  chance 
circumstance  may  bring  this  about.  In  other  cases  it  is  the  anoma- 
lous or  false  kinsesthetic  sensations  that  bring  about  constriction 
of  the  field  of  intellect  and  of  the  affections — hypochondriacal  mono- 
ideism,  or  monotonia,  with  strange  poses,  stereotyped  or  mutable. 

Observation  XI. — P.  L.,  eighteen  years  old,  belongs  to  a weak  family 
not  free  from  psychopathic  taint.  He  is  by  no  means  remarkable  for 
mtelligence.  He  went  to  school  without  profiting  much  therefrom,  and 


554 


PSYCHIATRY 


he  never  succeeded  in  learning  any  trade.  He  does  not  appear  to  possess 
ordinary  keenness  of  observation  and  of  judgment.  Two  months  before 
he  was  received  into  my  clinique  he  presented  a strange  bodily  attitude, 
the  neck  and  upper  part  of  the  spine  being  inclined  forward,  the  pelvis 
also  forward,  and  the  middle  part  of  the  spine  curved  outwards.  This 
pose  recalled  the  masturbatory  attitude,  but  was  greatly  exaggerated. 
At  the  same  time  there  was  a kind  of  stupor,  with  marked  slowness  of 
perception  and  incapacity  to  understand  questions,  these  being  answered 
slowly  and  inadequately. 

On  objective  examination,  the  tactile  sensibility  was  found  to  be 
unaffected.  The  sensibility  to  pain  was  much  diminished  all  over  the 
body,  and  particularly  so  on  the  inner  aspect  of  the  thighs.  There  was  a 
slight  concentric  restriction  of  the  fields  of  vision  of  both  eyes. 

A careful  psychological  examination  revealed  a dream-like  state,  in 
which  he  was  almost  completely  abstracted  from  reality.  He  hardly  ever 
managed  to  grasp  the  meaning  of  what  was  said  to  him,  and  he  could  not 
form  any  judgment  upon  persons,  things,  or  circumstances.  The  asylum, 
the  doctors,  the  hospital  attendants,  and  patients  with  severe  illnesses 
passed  for  a long  time  before  his  eyes  without  his  taking  any  notice  of 
them  or  being  able  to  identify  them.  There  was  no  sign  of  hallucinations 
or  deliria,  and  no  impulse  whatsoever.  He  had  every  appearance  of  being 
in  a pose  that  had  been  protracted  for  weeks  and  months,  and  one  which 
was  without  any  active  content,  either  ideative  or  emotive. 

Suggestive  treatment  with  strong  shocks  of  static  electricity  and 
energetic  commands  was  adopted.  The  effect  was  rapid.  In  a short  time 
he  resumed  the  upright  position,  and  his  mental  field  also  became  clearer. 
He  was  discharged  recovered. 

Observation  XII. — B.  L.,  aged  twenty-two,  was  ill  for  about  two 
months  before  his  admission  to  the  clinique.  It  was  following  upon  intense 
emotion  when  he  was  already  reduced,  very  probably  by  onanism,  that 
he  fell  ill.  His  tone  is  hypochondriacal.  When  admitted  he  was 
shrivelled  and  contracted,  his  limbs  being  rigid  and  his  eyes  closed.  To 
the  many  questions  put  to  him  his  only  answer  was,  ‘ I am  paralyzed.’ 
When  put  to  bed,  he  will  generally  remain  rigid,  his  eyes  closed,  while  his 
hands  assume  the  strangest  positions.  If  he  is  obliged  to  get  out  of  bed 
by  some  energetic  order,  he  presents  the  classic  form  of  astasia-abasia. 
Sensibility  appears  to  have  been  lost,  for  it  is  difficult  to  obtain  any 
response  from  him  ; there  is  reaction  to  severe  pricks  only.  The  muscular 
nutrition  and  the  deep  and  superficial  reflexes  are  normal.  He  stays  for 
whole  days  in  bed  with  his  eyes  closed,  and  with  the  upper  limbs  more  or 
less  stiff  and  rigid.  He  drinks  his  milk  and  eats  his  macaroni  ; he  is 
indifferent  to  everything  that  goes  on  around  him,  and  he  is  preoccupied 
with  his  paralysis,  to  the  exclusion  of  all  else.  His  attitudes  are  caused 
by  a real  monoideism  like  a fixed  idea.  After  he  had  been  in  the  clinique 
for  a few  days  he  had  lucid  intervals,  during  which  one  could  talk  with 
him.  The  psychological  examination  made  at  that  time  showed 
that  all  the  elementary  processes  of  the  mind — perception,  attention, 
memory,  and  ideation — were  poor  and  flaccid.  There  was  no  qualitative 
disturbance  of  the  perception.  He  showed  complete  indifference  to  his 
family  and  to  other  people.  He  made  great  ostentation  of  his  illness, 
and  tried  in  every  way  to  interest  the  hospital  attendants  and  the  doctors 
in  his  sufferings.  He  was  utterly  incapable  of  thinking  of  anything  else, 
and  it  was  impossible  to  turn  his  attention  to  any  other  subject. 

Suggestive  treatment  was  adopted  in  the  form  of  static  electricity 
discharged  with  strong  sparks,  and  energetic  orders.  This  brought  about 
a rapid  and  progressive  improvement,  during  which  one  could  note  the 
enlargement  and  the  recomposition  of  the  psychic  personality  in  propor- 


hysterical  insanity 


555 


tion  as  the  contractures  and  the  astasia-abasia  disappeared  and  the  sensi- 
bility returned.  That  happened  in  a few  days. 

Fourteen  months  after  he  had  been  dismissed  from  the  asylum,  coni- 
pletely  cured,  he  was  readmitted  in  a condition  of  stupor  very  like  organic 
stupor,  with  alternations  of  psycho-motor  agitation.  He  refused  tood, 
and  from  time  to  time  had  an  impulse  to  attack  other  persons.  It  is  not 
improbable  that  the  malady  assumed  this  form  owing  to  unconscious 
imitation,  for  in  our  hospital  there  are  very  numerous  cases  of  stupor, 
of  sensory  delirium  with  psycho-motor  agitation,  and  of  dementia  pr^ecox. 
It  was  noticed,  however,  that  when  our  patient  was  not  watched  he  would 
quite  readily  eat  more  than  his  share  of  the  rations ; and,  facilitating  the 
diagnosis,  there  was  a contracture  of  the  right  lower  limb  on  the  pelvis. 

For  the  second  time,  he  improved  in  the  asylum,  so  that  at  the  begmmng 
of  June  it  might  be  said  that  he  had  entered  on  convalescence.  One 
morning,  after  I had  strongly  reproved  him  for  the  theatrical  parade  oi 
illness  and  for  his  unwi]lingness  to  work,  he  was  seized  by  a convulsive 
attack,  with  impulses  to  violence.  Still,  that  did  not  retard  his  cure, 

which  was  rapid  and  complete.  u t • 

I was  not  in  time  to  take  the  photograph  of  this  patient,  but  I give 
here  that  of  another  youth,  who,  consequent  upon  strong  emotion,  had 
been  for  a month  in  “the  pose  that  is  photographed.  He  also  showed 
muscular  rigidity  and  great  resistance  to  passive  movements,  while  there 
was  a notable  degree  of  stupor,  closely  resembling  katatonia.  All  will 
power  was  extinguished,  and  he  had  much  the  appearance  of  a person 
fascinated.  This  pose  also  reminds  us  of  a sexual  attitude. 

The  facts  hitherto  collected  show,  on  the  one  hand,  the  parallelism 
between  somatic  and  psychic  phenomena  of  hysteria,  and,  on  the 
other,  the  great  disturbance  of  balance  of  the  psychic  activities, 
which,  like  waves,  rise  to  a great  height,  only  to  fall  again 
to  a level  much  below  that  of  the  physiological  oscillations  of  the 
mind.  The  hypersesthesia  is  concomitant  with  greater  perceptive 
power,  limited  to  the  hypersensitive  sense,  whilst  the  anaesthesia 
is  generally  accompanied  by  a depression  in  tone  of  the  activities 
of  the  personality,  and  sometimes  even  by  abolition  of  all  mental 
activity.  The  increased  perceptive  power  of  the  hysterical  subject 
is  not  utilized  by  the  mind,  which  is  incapable  of  high  products, 
and  not  well  adapted  for  the  formation  of  stable  syntheses,  which 
are  always  the  expression  of  a strong  mental  organization. 

This  being  so,  it  seems  to  me  needless  to  discuss  the  question 
of  the  existence  of  hysterical  insanity.  To  assert  that  hysterical 
insanit}^  is  nothing  more  than  a form  of  hereditary  degeneration, 
as  Joffroy  maintained  at  the  Congress  of  Clermont  Ferrant  in  1894, 
or  to  bring  up  again  the  whole  qirestion  of  the  psycho-pathology  of 
hysteria,  would  be  to  disregard  the  importance  and  the  value  of  a 
great  number  of  facts,  which,  through  the  great  variety  of  forms 
that  they  assume,  afford  evidence  of  a psycho-pathological  dis- 
position which  will  alwaj^s  serve  as  a guide  in  the  classification  of 
the  clinical  forms  that  we  are  discussing,  and  in  the  ccnstitution 
of  a group  that  must,  and  ought  to  be,  recognised  under  the  name 
‘ hysterical  psychosis.’ 

Whatever  Fere  and  Pitres  may  think,  we  hold,  along  with  Regis, 


1 


556  PSYCHIATRY 

Mendelsohn,  and  others,  that  hysterical  insanity  exists  per  se,  with 
its  own  quite  special  characteristics.  It  assumes  the  most  diverse 
forms,  but  these  may  be  traced  back  to  cessation  of  the  functions 
of  more  or  less  extensive  zones  of  the  cerebral  mantle,  with  restric- 
tion of  the  field  of  consciousness  of  the  personality  and  preponderat- 
ing power  of  the  subconscious.  The  latter  invades  the  field  of  the 
consciousness,  and  in  emotive  and  hypersensitive  persons  is  met 
by  no  obstacle,  so  that  the  new  guest,  whether  external  or  internal, 
finds  the  components  of  the  personality,  not  well  organized  oiiginally, 

ready  to  place  themselves  at  its 
service.  This  gives  a new  content 
to,  and  impresses  a particular 
emotive  colouring  on,  the  per- 
sonality. The  facility  with  which 
the  content  of  the  consciousness, 
for  insignificant  internal  or  ex- 
ternal reasons,  appears  and  disap- 
pears, gives  the  hysterical  subject 
the  character  of  mobility,  and 
makes  her  appear  capricious, 
violent,  bizarre,  criminal,  or  gene- 
rous. If  I had  to  sum  up  the 
psycho-pathological  idea  in  one 
phrase,  I would  say  that  the 
hysterical  subject  has  an  infantile 
mind,  but  sexually  is  adult  and 
anomalous.  Thus  it  is  that  she, 
like  an  undisciplined  child,  is 
mobile,  capricious,  and  astute. 
She  obeys  the  craving  of  her 
instinct  for  pleasure,  which  has 
perhaps  been  perverted,  and  en- 
deavours to  elude  the  vigilance  of 
her  guardian  to  procure  pleasure 
for  herself.  With  childish  thought- 
lessness she  falls  in  love  with  the 
first  man  that  casts  a look  of  desire  upon  her,  and  she  will  leave 
her  young  husband  during  the  honeymoon  in  order  to  abandon 
herself  to  a sexual  orgy  with  someone  whose  name  even  she  does 
not  know. 

A patient  recently  placed  under  treatment  in  my  clinique  said 
to  me  : ‘ I love  my  iiusband,  I like  to  see  him,  and  I wish  him 
well.  I love  my  children,  too  ; but  many  a time  I have  been  the 
victim  of  my  fancy.  I readily  turn  aside  to  pursue  ideals,  and 
when  I think  I see  any  of  my  ideals  embodied  in  a man,  I have  not 
tlie  strength  to  control  m^-^self.  I abandon  home,  husband,  and 
children,  staying  away  two  or  three  days  at  a time.  Then  I see 


Fig-  76. — A Katatonic  Stereo- 
typed Pose  in  a Hysterical 
Subject. 


HYSTERICAL  INSANITY 


557 


that  this  state  of  things  can’t  continue,  and  either  I return  home 
or  they  come  and  fetch  me.’ 

Thus,  exalted  fancy  offers  the  hysterical  subject  a field  of  action 
with  no  obstacles.  The  primary  affections,  the  fundamental  ideas 
that  have  such  a large  share  in  the  guidance  of  conduct,  and  the 
ethical  sentiments  which,  in  the  case  of  the  strong,  form  an  insuper- 
able barrier  to  the  assaults  of  instinct,  abandon  the  field  of  con- 
sciousness, with  the  result  that  the  hysterical  subject  thoughtlessly 
pursues  the  object  of  the  moment. 

It  is  certain  that  hysterical  insanity  is  taken  advantage  of  and 
abused.  In  practice  there  is  great  confusion,  and  distinctions  are 
quite  arbitrary. 

One  form  of  hysterical  insanity  that  admits  of  no  discussion, 
and  which  is  of  hallucinatory  content,  is  the  form  accompanying 
the  phase  of  passional  poses  (Charcot),  following  a more  or  less 
violent  and  prolonged  attack  of  grand  hysterical  convulsions. 
After  the  phase  of  contortions  in  the  grand  attack,  the  subject, 
generally  a woman,  poses  in  the  most  extraordinary  attitudes  of 
religious  ecstasy,  of  pain,  of  fear,  of  love,  of  tenderness,  or  of  wonder. 
She  sees  her  lover  and  yields  to  him,  or  she  hears  music,  enthralling 
music  that  sends  her  into  ecstasies.  She  will  sit  on  her  bed  with 
her  elbows  on  her  knees,  her  fingers  entwined  in  her  hair,  her  face 
between  her  hands,  her  attitude  revealing  profound  affliction  or 
extreme  despair.  She  turns  her  eyes  to  heaven,  completely 
abstracted  from  the  world  of  reality.  She  talks  with  mystic  per- 
sonages ; she  walks  slowly,  enveloped  in  an  air  of  mystery,  etc. , 
or  she  will  remain  in  a lethargic  state  for  hours  at  a time,  eyelids 
drooping  and  tremulous,  her  eyes  turned  convulsively  upwards. 
This  condition  suddenly  ceases,  leaving  no  memory  of  itself.  The 
consciousness  is  completely  re-established,  if  we  except  the  abnormal 
character  that  remains,  more  particularly  in  those  exhibiting  grave 
marks  of  hysteria  ; but  the  patient  relapses  into  the  same  state, 
almost  always  at  the  same  hour. 

Sometimes,  instead  of  the  passional  attitude,  there  is  a state  of 
intense  psychic  exaltation.  The  patient  is  a prey  to  strong  excite- 
ment, of  various  content — painful,  threatening,  erotic,  hilarious 
with  weeping,  laughter,  and  mysterious  or  obscene  language, 
hallucinatory  visions  of  beasts,  and  states  of  terror.  There  is 
agitation  of  the  limbs,  the  pelvis,  or  the  head,  sometimes  with 
true,  recurring,  rhythmic  spasms.  Characteristic  of  these  states  is 
the  rapid  establishment  of  periods  of  remission,  during  which  the 
personality  is  completely  restored,  and  that  almost  instantaneously, 
only  there  is  equal  facility  in  the  relapse  into  the  former  psycho- 
somatic agitation  or  state  of  lethargy. 

Another  form  is  spontaneous  somnambulism,  during  which  the 
personality  of  the  subject  is  completely  changed.  She  speaks,  con- 
verses, and  acts  in  an  ordinary  manner  ; but  her  affections,  her  dis- 


558 


PSYCH  I A TRY 


position,  and  her  habits  are  changed.  When  she  returns  to  her 
original  condition,  sometimes  she  remembers  nothing  of  all  that 
she  has  done  in  her  altered  state,  at  other  times  she  remembers  and 
recounts  her  visions.  Such  a condition  of  matters  may  last  for 
moments,  days,  weeks,  for  many  months,  or  even  for  a year  or  so 
(see  Part  II.). 

Occasionally  the  hallucinatory  form  is  recurrent,  and  of  very 
simple  content — a sort  of  sensory  tic.  A young  woman  who  was 
under  my  treatment  had  a hallucination  of  a black  man  who  entered 
her  room  by  the  window,  and  this  recurred  eight  to  ten  times  a 
day,  almost  always  at  the  same  hours.  All  of  a sudden,  during  a 
conversation,  she  would  give  a cry  of  terror,  and  fall  into  a state  of 
lethargy,  from  which  she  recovered  in  thirty  minutes  or  an  hour. 
This  state  of  matters  lasted  about  four  months,  notwithstanding 
the  treatment. 

Sometimes  there  is  a so-called  attack  of  sleep  that  may  last 
for  days  or  for  a few  weeks.  During  that  time  many  organic 
functions  are  depressed,  and  the  patient  neither  eats  her  food  nor 
passes  urine.  It  is  difficult  for  even  the  most  skilful  medical  man 
to  awaken  a subject  in  this  condition. 

Years  ago  Professor  Senise  and  myself  saw  a young  woman 
of  about  eighteen  in  an  attack  of  sleep  that  had  then  lasted  a 
fortnight.  During  that  time  she  did  not  eat  or  drink,  and  she 
passed  urine  only  three  times.  It  was  only  by  applying  a strong 
current  of  faradic  electricity  to  the  vagi  nerves  that  I succeeded 
m reawakening  her.  She  at  once  resumed  her  ordinary  mode  of 
life,  although  she  complained  of  extreme  weakness.  She  awoke 
with  a spirit  of  hostility  to  me,  and  she  rudely  and  contemptuously 
rejected  my  proposal  to  treat  her  by  means  of  hypnotism,  in  order 
to  release  her  from  a malady  that  deprived  her  of  her  liberty  and 
caused  great  alarm  to  her  poor  parents.  Two  days  later  she  came 
to  my  house  all  smiles  and  compliments,  declaring  that  she  had 
unlimited  confidence  in  me,  and  offering  to  make  a start  with  the 
hypnotic  treatment  (hysterical  contradiction). 

Hysterical  melancholia,  mania,  and  paranoia  have  been  de- 
scribed. Schiile,  whose  clinical  acumen  is  well  known,  has  given 
a brief  description  of  these  forms,  and  many  others  have  followed 
his  example  (Mendel,  Krafft-Ebing). 

In  hysterical  mania  there  is  sometimes  a rapid  transition  from 
the  hypochondriacal  tone  of  mind  connected  with  the  altered  kin- 
.Tsthesis,  particularly  pains  in  the  ovaries,  knots  in  the  epigastric 
region,  and  constriction  of  the  throat,  to  a feeUng  of  relief  and  well- 
being, with  merry  and  joyous  tone,  great  facility  of  speech,  coquet- 
tishness that  is  full  of  wit,  and  an  unusual  and  thoughtless  transla- 
tion of  ideas  into  the  corresponding  acts.  Walks,  visits,  dressing, 
and  to  some  degree  overdressing,  festivities  and  theatres,  now  form 
the  main  preoccupation  of  the  subject.  Her  own  family  have  little 


HYSTERICAL  INSANITY 


559 


place  in  her  thoughts,  and  she  breaks  up  its  quiet  habits.  The 
sexual  instinct  is  heightened,  and  more  impulsive,  so  that  she 
abandons  herself  more  easily  and  more  frequently  to  amorous 
suggestions. 

The  sense  of  lightness  gives  the  hysterical  subject  a certain 
restlessness,  just  as  the  sense  of  well-being  and  vital  power  makes 
her  intolerant  of  reminders  or  correction,  which  she  sometimes 
contemptuously  resents.  At  times  she  will  break  out  into  fits  of 
fury  of  short  duration,  with  threatening  cries,  rebelliousness,  acts 
of  violence,  and  tendency  to  destruction.  At  other  times  this 
agitation  partakes  more  of  an  infantile  chaiacter,  and  then  the 
hysterical  subject  weeps,  cries,  refuses  to  eat,  and  rolls  on  the 
ground.  In  these  cases  it  is  by  no  means  rare  for  a convulsion  to 
close  the  period  of  mania,  after  which  either  the  subnormal  state 
proper  to  the  subject  is  re-established  or  the  personality  comes 
out  of  the  convulsion  under  another  form. 

In  contrast  to  the  constancy  of  genuine  mania,  we  find  charac- 
teristic of  such  maniacal  states  an  unusual  variety  of  phenomena 
the  signs  of  hysteria,  the  transitory  return  of  hypochondriacal  ideas 
awakened  by  painful  sensations,  and  the  convulsions  that  occur  and 
recur  during  the  course  of  the  malady. 

Hysterical  melancholia  is  specially  characterized  by  behaviour 
significant  of  pain,  but  almost  never  intense  or  profoundly  felt  or 
identified  with  the  ego.  In  most  instances  it  is  easy  to  discern  in 
hysterical  melancholia  only  a very  superficial  degree  of  suffering, 
notwithstanding  the  fact  that  the  patient  tries  in  every  way  to 
heighten  the  effect  and  to  draw  upon  her  ‘ pains  ’ the  pitying 
attention  of  friends  and  relatives.  The  dark  feeling  of  haunting 
and  obstinate  suffering  that  invests  the  mind  of  the  melancholia 
subject  and  drives  him  to  despair  is  lightened  in  cases  of  hysteria 
by  the  pleasure  that  is  derived  from  the  sympathy  of  others  with 
the  sufferings  of  the  patient,  and  by  a vague  hope  of  getting  free 
from  the  ‘ terrible  pains.’  The  mind  of  a melancholic  hysterical 
subject  never  reaches  that  degree  of  actual  and  profound  abase- 
ment which  in  the  case  of  melancholia  sometimes  extends  to  the 
negation  of  one’s  proper  personality.  As  a matter  of  fact,  suicide 
is  rare.  Here  also  the  personality  is  found  to  be  duplicated.  The 
pain  is  only  on  the  outside  of  life,  and  from  behind  the  curtain  the 
other  aspect  of  the  hysterical  personality  peeps  out  from  time  to 
time.  Under  the  influence  of  impressions  or  emotions  the  melan- 
cholic mask  is  dropped,  and  the  subject  reappears  in  her  original 
and  natural  figure. 

Hysterical  paranoia  is  even  more  frequent  than  mania  and 
melancholia.  It  assumes  various  forms,  the  most  common  being 
the  religious  and  the  erotic.  In  the  first  case  we  find  visions  of 
saints  and  religious  ecstasy,  whence  paranoic  ideas  spring  up, 
ranging  from  the  most  rudimentary  to  the  most  highly  developed. 


56o 


PSYCHIATRY 


Hysterical  mysticism,  which  ' is  associated  with  rudimentary 
paranoic  ideas  of  a religious  nature,  leads  to  ascetic  conduct,  with 
a tendency  to  theatrical  display.  In  more  serious  cases  real  de- 
lirious ideas  appear,  being  determined  by  hallucinations  or  by 
dreams  of  religious  content.  These  give  classical  paranoic  syn- 
theses, and  of  them  an  example  is  found  in  the  story  of  Joan  of 
Arc  (Ireland).  In  almost  all  subjects  of  this  second  category  we 
find  hysterical  blemishes,  particulaily  anaesthesia,  analgesia,  and 
rhythmic  spasms. 

Erotic  paranoia  also  assumes  various  forms — the  persecuting 
and  the  erotic  properly  so  called.  The  first  manifests  itself  in 
jealousy.  There  is  predominance  of  exuberant  egoism,  tyrannical 
and  indomitable.  The  poor  man  who  falls  into  the  net  of  the 
hysterical  jealous  woman  is  three  parts  lost.  She  shadows  his  steps, 
allots  the  hours  of  his  absence,  sometimes  follows  him  to  the  office, 
lays  wait  for  him  in  the  streets,  sends  spies  after  him,  watches  his 
every  movem.ent  and  every  look  that  he  casts  at  any  person  with 
whom  he  has  an  appointment  or  with  whom  he  chances  to  be  in 
contact.  False  interpretations  are  frequent,  also  illusions,  or  simply 
illusionary  interpretations  of  the  most  innocent  phrases;  and  in 
such  a case,  which  occurs  quite  frequently,  the  family  is  treated  ■ 
to  violent  scenes  of  crying,  insults,  threats,  and  blows,  of  which  . 
the  poor  husband  is  the  victim.  Neither  entreaty,  loving  behaviour,  : 
nor  prudence  is  of  any  effect  in  calming  the  diabolic  spirit.  After  ' 
some  time  hysterical  convulsions  will  perhaps  supervene  and  close  , 
the  scene.  In  more  serious  cases  the  delusion  takes  the  form  that  ' 
the  women  or  ladies  of  the  neighbourhood  are  trying  to  attract  the 
husband  to  themselves.  The  subject  already  notices  that  they  are 
casting  languishing  glances  at  him,  and  that  they  look  on  her  with 
jealous  eyes,  no  longer  treating  her  as  before.  Cordiality  and  : 
courtesy  are  reserved  for  her  husband  alone.  She  has  already  heard  ] 
various  loving  expressions  pass  between  them  (illusions),  and  so  { 
she  threatens  and  insults  her  poor  innocent  neighbours,  who  abandon  j 
her  to  the  most  miserable  solitude.  Some  such  women  force  their  \ 
husbands  to  frequent  copulation,  not  so  much  from  libidinousness, 
for  often  subjects  of  this  class  are  very  little  addicted  to  the  pleasures 
of  love,  but  rather  to  exhaust  the  energies  of  the  unhappy  man,  so 
that  it  may  be  impossible  for  him  to  have  sexual  relations  with  other 
women.  And  when  the  poor  man  cannot  or  will  not,  the  wild 
scenes  of  weeping  and  crying,  threats  and  petty  insults,  are  renewed. 
Not  a few  cases  of  loss  of  virility  are  due  to  wives  or  mistresses  who 
are  lu^sterically  jealous. 

This  state  is  interspersed  with  periods  of  endearment  and  loving 
behaviour  (hysterical  contrast),  or  it  may  be  subcontinuous  and 
aggravated  during  menstruation  ; or,  again,  it  may  be  recurrent 
at  the  menstrual  periods.  This  last  is  the  most  frequent  form  of 
]')criodical  insanity  in  women. 


HYSTERICAL  INSANITY 


561 


The  second  form  comprises  those  women  who,  with  minds 
originally  ruled  by  erotic  ideas,  either  restrict  themselves  to  the 
domain  of  the  ideal,  and  are  the  platonic  dreamers  of  love,  01 
become  in  some  cases  the  persecutors  of  men  who  have  had  the 
misfortune  to  come  in  contact  with  them;  for  they  resort  to  wheedling 
of  every  sort,  breathing  forth  sighs,  sending  flowers,  and  writing 
long  love-letters  when  they  are  about  fifty.  In  most  cases  they 
refuse  copulation. 

The  erotic  idea  sometimes  descends  to  the  level  of  instinct,  and 
becomes  confounded  with  it.  In  these  cases  the  sexual  sensibility 
is  intense,  the  appetite  is  keen,  and  almost  always  unsatisfied.  A 
species  of  sexual  erethism  subjugates  the  personality,  overcomes 
it,  and  rules  it  periodically.  A feast  leaves  her  unsatisfied,  and 
pleasure  polarizes  her  mind.  A husband  or  a lover  will  not  satisfy 
her  unbridled  lust,  and  the  first  comer  is  accepted  as  a companion. 
Neither  shame  nor  the  honour  of  her  house  has  any  influence  over 
her — from  master  to  servant,  in  the  bedchamber,  the  boudoir,  or 
the  stable — for  the  brutal  instinct  will  suffer  no  restraint.  All  the 
products  of  civilization,  honour,  and  decency,  lose  their  value  for 
hysterical  subjects  of  this  class  (nymphom.ania).  This  condition 
also  is  mutable. 

Cases  of  hysterical  persecutory  paranoia  also  occur.  I give 
below  a short  summary  of  an  interesting  case. 

Observation  XIII. — C.  M.,  elementary  school  teacher,  was  sent  to 
the  Naples  asylum  in  August,  1902,  from  the  criminal  asylum  of  Aversa, 
as  he  had  been  guilty  of  homicide.  For  some  time  previously  he  had  been 
manifesting  a notably  psychopathic  constitution,  characterized  by  sus- 
picion and  tendency  to  isolation,  and  these  features  had  gradually  become 
very  much  accentuated.  Things  reached  such  a point  that  one  day, 
finding  the  servant  girl,  who  was  also  his  mistress,  speaking  with  strangers 
and  the  door  of  the  house  open,  he  believed  that  he  saw  in  that  a proof  of 
a preformed  design  to  rob  and  murder  him,  and,  snatching  up  a razor, 
he  killed  the  girl. 

On  inspection,  he  showed  no  anthropological  marks  of  degeneracy. 
Examination  of  the  functional  organs  showed  complete  hemianaesthesia 
of  all  forms  of  sensibility  on  the  left  side,  with  hyperaesthesia  and  hyper- 
algesia on  the  right.  The  senses  of  smell  and  of  taste  on  the  left  side  were 
gone.  There  were  hemianopsia  and  deafness ; hemiparesis  on  the  left, 
including  the  upper  part  of  the  face  ; bradyphasia  and  bradyphrasia 
with  extensive  amnesia,  and  agraphia. 

The  patient  has  an  ordinary  physiognomy.  He  appears  unsusceptible 
to  the  stimuli  that  reach  him  from  the  outer  world,  nor  is  it  evident  that 
his  abstraction  from  the  influence  of  his  surroundings  is  the  effect  of  con- 
centration of  the  psychic  activity  on  the  products  of  a diseased  inner  life. 
He  retains  elementary  perceptions,  and  recognises  places  and  persons 
perfectly,  especially  after  they  have  been  pointed  out  to  him.  He  knows 
that  he  is  in  an  asylum,  not  because  he  has  derived  the  idea  from  the 
synthetic  judgment  of  what  he  has  perceived  in  his  new  surroundings, 
but  because  he  has  heard  it  repeated  by  others.  His  own  perceptive 
power  is  much  reduced  in  comparison  with  what  it  must  have  been  pre- 
viously, seeing  that  he  was  a teacher  in  an  elementary  school. 

The  power  of  meuiory  presents  the  most  considerable  disturbances. 

36 


562 


PSYCHIATRY 


The  whole  of  his  life  up  to  the  date  of  his  admission  into  the  asylum  of  i 
Aversa  forms  a vast  gap  in  his  memory.  He  no  longer  knows  that  he  was  1 
once  an  elementary  teacher,  and  in  the  same  way  he  remembers  nothing  ■ 
at  all  of  the  crime  with  which  he  is  charged.  We  can  measure  ap-  i 
proximately  that  enormous  loss  of  recollections,  and  we  find  it  extending  I 
also  to  the  sensory  and  ideative  regions.  Almost  all  the  images  of  places  ' 
have  disappeared.  This  man,  who  has  passed  a good  part  of  his  life  in 
Naples,  and  who  should  be  able  to  indicate  the  streets  and  squares  of  that 
city,  IS  not  mentally  capable  of  following  out  any  single  itinerary  what- 
soever. Almost  all  the  images  of  persons  are  forgotten.  A brother  of 
his,  a priest,  came  to  visit  him,  but  was  not  recognised  by  him.  The 
only  surviving  image  of  a person  is  that  of  another  brother  who  : 
visited  him  at  the  time  when  he  was  received  into  the  asylum  of  Aversa.  | 
The  images  of  common  objects  are  also  lost  in  great  measure.  He  ' 
lived  m a maritime  city,  yet  he  no  longer  knows  what  a ship  or  a j 
boat  IS.  Leaving  the  sensory  memory,  we  find  that  the  patrimony  of  I 
abstract  ideas  has  become  extremely  impoverished.  To  give  an 
example,  this  one-time  teacher  in  an  elementary  school  cannot  even 
tell  what  a school  is. 

The  defects  of  language  are  particularly  classical.  Besides  losing  a 
great  number  of  the  substantives  that  apply  to  abstract  ideas  and  concrete 
objects,  and  in  addition  to  the  loss  of  the  fluent  use  of  phrases  formerly  at 
his  command,  and  that,  moreover,  to  such  an  extent  as  to  force  hirn  in  j 
most  cases  to  make  use  of  colloquial  expressions,  he  has  completely  for-  ! 
gotten  how  to  read  and  write.  If  he  is  asked  to  read  a book  or  a newspaper  I 
he  is  quite  at  a loss,  and  does  not  know  what  to  do.  Not  only  is  he  > 
incapable  of  recognising  a word  as  a whole,  but  he  does  not  even  recognise 
the  separate  syllables  and  letters.  He  has  lost  the  power  of  writing 
spontaneously  and  to  dictation.  He  can  only  copy,  and  that  in  the  same  ' 
way  as  would  be  done  by  a person  reproducing  lines  that  had  no  meaning  ' 
for  him. 

A mere  enumeration  of  the  phenomena  presented  by  this  patient,  ; 
whose  history,  the  subject  of  a very  interesting  study  by  Drs.  Patini  and 
Mele,  is  reported  in  the  Annali  di  Nevrologia  for  1902,  will  prove  the  rarity 
and  the  mportance  of  the  case.  It  is  rare  because  of  the  somatic  pheno- 
mena, such  as  the  facial  paralysis  and  the  hemianopsia,  and  important 
because  it  pioves  the  connection  that  exists  between  the  somatic  and  the  ’ 
psj^chic  phenomena  of  hysteria,  although  that  connection  may  be  more  or  ' 
less  strict  in  different  cases.  Whatever  the  objections  that  may  be  raised  i 
as  to  the  origin  and  nature  of  the  somatic  phenomena,  or  at  least  some  of  i 
them,  particularly  the  hemianopsia,  of  which  some  other  cases  are  known  ' 
(Janet,  Lannois,  Fournier,  Harris),  having  reference  to  hysteria,  those  S 
objections  are  overruled  by  the  modifications  that  were  noted  in  the  course  ' 
of  the  malady,  especially  the  rapid  and  complete  disappearance  of  the  I 
hemianopsia  along  with  the  hemianaesthesia,  and  the  gradual  and  pro-  ‘ 
portionate  return  of  the  intellect  and  the  capacities  of  the  former  psychic 
personality.  After  a long  and  careful  examination,  resulting  in  the  diag- 
nosis of  a hysterical  somatic  syndrome,  with  return  of  the  personality  to 
Its  infantile  form,  and  after  the  psychic  treatment  of  this  patient  had  ! 
been  entered  upon  in  the  manner  suggested  bv  the  nature  of  the  disease,  . 
the  reintegration  of  the  personality  was  relatively  rapid.  Up  to  the  ' 
beginning  of  December  the  syndrome  had  remained  unaltered.  On  1 
Decembei  9 the  patient  began  to  read,  spelling  out  the  words.  The  j 
tactile  hemianaesthesia  diminished,  while  sensibility  was  almost  re-  j 
established  m the  forearm  and  in  the  left  hand;  the  temporal  hemi-  1 
ano})sia  on  the  right  disappeared.  \ 

()n  Januaiy  27,  1902,  the  patient  could  read  fairly  fluently,  and  could  ! 
also  write  to  dictation,  although  with  much  difficulty.  The  field  of  his  1 


HYSTERICAL  INSANITY  563 

memory  was  extending  ; he  could  realize  his  present  circumstances,  and 
was  commencing  the  reconstruction  of  his  history. 

On  February  22  the  hemianaesthesia  was  much  reduced.  The  sensi- 
bility was  normal  at  the  knee,  the  groin,  and  the  chest ; at  all  other 
parts  it  was  much  diminished,  but  not  abolished.  Simultaneously  the 
ideative  field  was  broadening  and  the  psychic  personality  reconstituting 
itself ; but  a great  deal  was  still  wanting  for  the  complete  restoration  of 
the  original  character. 

About  the  beginning  of  April  the  personality  was  almost  completely 
reintegrated.  The  patient  could  give  a detailed  account  of  how  he  had 
killed  the  woman.  One  single  gap  in  memory  yet  remained  to  be  filled 
up.  Still,  he  was  like  a person  preoccupied,  and  prevented  from  using  his 
mind  by  some  tormenting  thought  that  could  not  be  formulated  or  repre- 
sented, and,  in  the  meanwhile,  of  the  somatic  phenomena  there  still  persisted 
the  arthralgia  of  the  left  shoulder-joint,  and  the  paresis  of  the  left  upper 
limb.  Towards  the  end  of  April  all  the  somatic  phenomena  had  disap- 
peared except  a slight  paresis  of  some  muscles  in  the  upper  part  of  the 
face,  and  at  the  same  time  the  patient  had  been  perfectly  restored,  no 
blank  remaining  in  the  history  of  his  past  life. 

I give  three  specimens  of  writing  taken  from  the  account  drawn  up  by 
Drs.  Patini  and  Mele,  and  with  the  greater  assurance  because  these  facts 
were  verified  by  myself  during  my  customary  visits  to  the  patients  in 
the  climque.  The  three  styles  of  writing  form  graphic  representations  of 
three  stages  in  the  process  of  reintegration  of  this  patient. 

We  know  neither  the  pathological  anatomy  nor  the  physio- 
pathology  of  hysteria.  We  do  know,  however,  that  no  matter 
how  frequent  or  intense  the  hysterical  convulsions  may  be,  mental 
decadence  is  not  a necessary  consequence.  The  return  ad  integrum 
is  almost  always  instantaneous  and  complete.  Everything  goes  to 
prove  the  existence  of  a chemical  metabolism,  with  the  formation 
of  cohibiting  substances  from  the  nervous  wave  in  some  parts  of 
the  brain,  and  the  speedy  resumption  of  the  atomic  constitution  of 
the  cellular  substance  and  of  the  nervous  reticules,  both  intra-  and 
extra-cellular.  These  changes,  which  may  be  compared  also  to  the 
isomeric  states,  are  compatible  with  the  life  and  the  fine  structure 
of  the  cells  and  the  reticules,  so  that  these  resume  their  original 
function,  even  after  a long  interval,  just  as  a normal  electric  apparatus 
would  do  when  the  current  is  given  access  to  it. 

It  is  certain  that  if  the  neurone  doctrine  had  not  been  shaken 
to  its  foundations  by  recent  histological  researches,  one  of  the  best 
applications  of  it  would  have  been  that  made  by  I.epine  in  the 
interpretation  of  the  phenomena  of  hysteria.  Given  the  amoeboidism 
of  the  ramifications  of  the  protoplasmic  prolongations  and  the 
necessity  of  tiie  contacts  for  the  passage  of  the  nerve-waves  (see 
Part  I.),  then  our  minds  might  rest  content  with  an  interpretation 
of  hysterical  phenomena  as  the  expression  of  a tetanoid  condition 
of  the  arborisations,  impeding  the  passage  of  the  nerve  - waves, 
or  an  abnormal  prolongation  of  some  contacts,  giving  rise  to 
that  functional  interdiction  of  small  or  extensive  regions,  cortical 
and  infracortical,  which  is  the  preponderant  and  fundamental 
phenomenon  of  hysteria.  But  too  much  has  already  been  said  on 

36—2 


PSYCHIATRY 


5&-1 


/# 


Fig.  77. — Writing  in  the  First  Stage  of  Improvement. 


Fig.  78. — Writing  at  an  Advanced  Stage  of  Improvement. 


Fig.  7q. — Normal  Writing,  after  Complete  Recovery 


HYSTERICAL  INSANITY 


565 


the  neurone  doctrine,  which  formed  a convenient  explanation  of  so 
many  things,  for  that  doctrine  is  almost  dead.  Excepting  trau- 
matic hysteria,  which  is  a complex  psycho-neurosis,  and  leaving 
complications  aside,  we  cannot  speak  of  pathological  anatomy  of 
hysteria. 

.Etiology. — Heredity,  direct  and  similar,  is  the  principal  source 
of  hysteria.  The  hysterical  mother  generally  begets  hysteria  in  the 
daughter,  often  aggravated  by  more  advanced  psycho-somatic 
degeneration.  Neurasthenia,  alcoholism,  and  epilepsy,  are  the 
neuro-psychopathic  states  that  are  most  intimately  connected  with 
hysteria. 

Education  and  surroundings  have  great  setiological  value.  All 
circumstances  and  conditions  of  life  that  interfere  with  contact  with 
reality  favour  a frail  mental  constitution,  with  little  resisting  power. 
Given  a predisposition  to  psychopathia,  individuals  with  dreamy 
and  fantastic  natures,  fond  of  contrasts  and  paradoxes,  nourishing 
themselves  on  sensational  romances,  and  finishing  by  seeking 
adventures  or  by  failing  to  attach  themselves  to  the  realities  of 
life  in  their  own  families  and  in  their  social  surroundings,  are  those 
that  are  most  frequently  subject  to  hysteria,  and  more  particularly 
in  the  case  of  women. 

Labour,  discipline,  and  the  pressure  of  reality  are  good  cements 
for  the  factors  that  make  up  a personality.  A proof  of  this  is  found 
in  the  fact  that  in  the  army  hysteria  is  very  rare.  An  easy,  indolent 
life  and  sensuousness  are  excellent  contributors  to  hysteria. 
Mysticism  and  asceticism  are  thus  closely  bound  up  with  the  history 
of  hysteria,  because  they  withdraw  people  from  reality,  exalt  sen- 
suality, and  allegorically  they  excite  those  combats  between  the 
intellect  and  the  instincts,  the  victory  always  lying  with  the  latter, 
which  rush  in  from  the  subconscious  after  long  repression,  when  the 
brain  is  most  worn  out  and  wearied  with  the  long  struggle  and  with 
onanism.  Thus  it  is  that  nuns  furnish  by  far  the  largest  propor- 
tion of  hysterical  subjects.  The  enforced  chastity,  particularly  in 
individuals  endowed  with  fervid  natures,  exalts  the  sexual  instinct 
to  a still  higher  degree,  and  the  hysterical  convulsion  serves  to 
reveal  the  sexual  trouble  that  has  brought  it  about  in  most  cases. 
Except  in  cases  of  infantile  hysteria,  the  majority  of  hysterical 
subjects  are  over  twenty-two  years  of  age,  worn  out  with  desire  and 
long  expectation,  without  a ray  of  hope  to  lighten  the  sadness  of 
the  long  despairing  wait.  The  onanism  to  which  they  abandoned 
themselves  in  infancy,  and  often  continue  in  youth  and  maturity, 
exalts  the  sexual  desire  and  instinct,  with  all  the  train  of 
phenomena  of  par^esthesia  and  malaise  that  prepare  the  ground  for 
the  irruption  of  convulsions  under  the  slightest  emotion. 

In  this  regard  not  only  am  I inclined  to  accept  the  ideas  of  Freud 
as  to  the  importance  of  sexual  images  that  have  passed  into  ‘ the 


566 


PSYCHIATRY 


unconscious  ’ in  the  genesis  of  hysteria,  but  I may  say  that  I have 
no  doubt  at  all  on  the  question. 

The  main  movements  and  the  contortions  of  the  hysterical 
subject  often  present  a sexual  character,  and  the  poses,  such  as 
that  shown  in  Fig.  76,  are  nothing  else  than  psycho-motor  stereo- 
types, and  often  recall  sexual  attitudes. 

Certainly  the  sexual  instinct,  precocious,  perverted,  or  repressed, 
does  not  possess  such  genetic  power  in  all  cases  ; but  an  inquiry  into 
this  subject  has  furnished  me  with  evidence  of  the  greatest  value 
as  to  the  preponderating  importance  of  the  sexual  life  in  the  genesis 
of  hysteria.  The  majority  of  hysterical  women,  in  whom  can  be 
traced  a genetic  relation  between  the  hysteria  and  insanity  on  the 
one  hand  and  the  ovaries  on  the  other,  suffer  also  from  burning 
heat,  prurient  itching,  or  intense  desires  in  the  vulva  and  vagina, 
which  sometimes  compel  onanism,  and  sometimes  are  the  result  of 
it.  Very  often  it  is  these  sensations  that  excite  the  convulsive 
attacks  when  they  reach  a high  degree  of  intensity,  as  at  the 
period  of  menstruation,  and  for  some  time  before  and  after. 

Strong  emotions,  contrasts,  mental  sufferings,  disillusionments, 
economic  ruin,  loss  of  loved  ones,  are  immediate  and  efficacious 
causes  only  when  they  act  upon  natures  that  are  hysterical,  either 
originally  or  by  acquisition. 

The  reading  of  books  dealing  with  spiritualism,  presence  at  ^ 
spiritualistic  or  hypnotic  seances,  and  hypnotic  practices,  are  good 
provocative  agents  ; but  the  truth  is  that  it  is  just  those  persons 
of  hysterical  nature  who  run  after  these  mystical  and  emotional 
representations,  and  develop  so  strong  a passion  for  them  that  they 
end  by  being  their  victims. 

Physical  traumata  are  a frequent  cause  of  hysteria.  These 
cases  prove  the  existence  of  latent  hysteria,  which  the  injury  brings 
into  evidence. 

Imitation  acts  in  the  same  way,  especially  where  the  surrounding 
conditions  are  similar  in  point  of  age,  sex,  mode  of  life,  and  the 
dominating  ideas  or  emotions  in  the  whole  society.  It  is  in  this 
way  that  we  explain  the  numerous  hysterical  epidemics  of  the 
Middle  Ages,  to  which  the  monasteries  contributed  such  a large 
number.  In  later  days  we  have  also  had  examples  of  these  in  Italy 
and  elsewhere.  Palmer,  of  Riberach,  mentions  an  epidemic  of 
narcolepsy  in  a Catholic  school,  where  thirteen  girls  between  twelve 
and  fourteen  years  of  age  were  attacked. 

In  an  institution  at  Rome  a girl  suffered  from  coxalgia  as  the  result 
of  a fall.  Some  time  afterwards  another  girl,  a companion  of  the 
first,  and  daughter  of  a neuropathic  father  who  died  of  melancholia 
a long  time  afterwards,  slipped  in  the  same  boarding-school,  but 
did  not  fall.  The  next  day  she  presented  a syndrome  closely 
resembling  that  of  her  companion,  showing  symptoms  of  coxalgia 
down  to  the  smallest  details.  The  resemblance  to  the  syndrome 


HYSTERICAL  INSANITY 


567 


of  coxalgia  was  such  that  the  most  distinguished  surgeons  in  Rome 
and  Naples  were  put  to  a severe  test  in  dealing  with  the  case.  The 
discovery  of  anaesthetic  and  hyperalgesic  zones  in  the  two  lower 
limbs,  and  the  profound  change  of  character  in  this  girl,  who,  from 
being  one  of  the  best  pupils  in  the  school,  had  become  capricious 
and  crossgrained,  revealed  to  me  the  true  nature  of  the  coxalgia. 
Perhaps  the  way  was  prepared  by  my  conviction,  frankly  expressed 
in  her  presence,  by  way  of  suggestion,  but,  be  that  as  it  may,  the  girl 
recovered  on  being  awakened  one  morning  by  martial  music  as  the 
soldiers  passed  under  the  balcony  of  her  house. 

All  debilitating  maladies,  anaemia,  maladies  of  the  sexual  sphere, 
and  troubles  of  the  digestive  organs,  prepare  the  way  for  hysteria, 
which  must  always  be  regarded  as  a constitutional  malady,  develop- 
mental or  acquired,  consisting  in  the  incapacity  of  the  brain  to 
maintain  the  psychic  unity  of  the  subject,  and  therefore  the  ten- 
dency to  complete  or  incomplete  duplication  of  personality. 

Diagnosis. — The  slighter  degrees  of  hysteria  are  not  easily 
diagnosed.  They  are  lost  in  the  large  borderland  between  normal 
and  pathological  states,  and  are  confused  with  characters  which  we 
generally  look  upon  as  normal,  according  to  the  particular  national 
or  racial  disposition. 

Some  women  are  eccentric,  original  and  mobile  characters,  yet 
they  possess  a certain  immutable  nucleus  in  their  personality,  and 
present  no  mark  of  hysteria ; others  are  jealous  and  violent,  but 
there  are  limits  to  the  disorder,  and  they  cannot  be  classed  as 
insane ; others,  again,  are  eminently  hypersensitive  on  the  emo- 
tional side  ; still  others  are  excessively  romantic  and  fantastical, 
but  their  behaviour  is  correct,  and  they  never  fail  in  their  duties 
to  their  families  or  their  social  obligations  ; whilst  others,  again,  are 
very  lascivious,  but  are  kept  within  bounds  by  feelings  of  shame, 
decency,  and  duty.  In  all  these  characters  we  can  quite  well  trace 
a real  hysterical  rudiment,  but  the  diagnosis  of  true  hysteria  is 
founded  upon  the  exaggeration  of  hysterical  manifestations,  upon 
the  existence  of  convulsions,  whatever  their  degree  and  form, 
upon  the  presence  of  hysterical  signs — anaesthesia,  analgesia,  hyper- 
aesthesia,  hystero-genetic  zones,  kinaesthetic  disturbances,  restriction 
of  the  field  of  vision — which  must  be  looked  for  in  all  parts  of  the 
body,  and  then  those  more  classical  signs — hemianaesthesia,  paralysis, 
contractures,  arthralgias,  the  semeiotic  history  of  which  could  not 
fittingly  be  discussed  here.  For  us  equal  value  must  be  attached 
to  those  partial  or  total  duplications  of  the  personality,  which  range 
from  simple  change  of  character  and  of  the  affective  tone  to  an 
altogether  peculiar  and  different  character,  with  or  without  amnesia, 
and  to  the  ethical  perversion  of  the  personality  itself. 

This  is  not  the  place  to  discuss  the  difierential  diagnosis  of 
hysterical  and  epileptic  convulsions.  Whatever  be  the  form  of 


568 


PSYCHIATRY 


the  hysterical  psychosis,  it  is  marked  by  the  same  mobility  and 
tendency  to  disaggregation  that  characterize  the  hysterical  mind. 
The  description  that  I have  given  of  it  in  the  short  sketches 
occurring  in  this  chapter  will  serve  as  a guide  for  the  recognition  of 
true  hysterical  insanity  as  contradistinguished  from  those  other 
forms  of  insanity  that  complicate  hysteria,  and  each  of  which 
presents  a clinical  picture  of  its  own. 

Prognosis —The  outlook  is  much  more  hopeful  than  in  epilepsy. 
Both  these  forms  of  neurosis  are  constitutional,  each  in  its  own  par- 
ticular way.  In  epilepsy  there  is  an  impediment  to  the  free  course 
of  the  nerve-waves.  In  hysteria  the  course  is  too  easy  and  too  free  for 
these,  so  much  so  that  zones  of  greater  or  less  extent  remain  with 
a potential  inferior  to  what  is  necessary  to  the  conscious  personality 
for  the  performance  of  its  functions.  In  epilepsy,  if  the  personality 
does  not  originally  present  the  characteristic  of  destructive  malignity, 
it  will  gradually  acquire  it  ; in  hysteria,  on  the  other  hand,  the 
personality  assumes  a theatrical  character.  The  epileptic  is  eccentric 
in  the  sense  that  he  reacts  destructively,  and  he  remains  so  ; but  the 
hysterical  subject  is  egocentric  in  the  sense  that  she  takes  pleasure 
in  making  herself  a centre  of  interest  for  those  about  her,  upon 
whom  she  reacts  by  her  use  of  the  wonderful  and  strange,  serving 
up  to  her  people  a daily  dish  of  troubles  and  annoyances,  sometimes 
calculated  to  drive  them  to  despair. 

In  the  majority  of  cases  this  condition  is  only  temporary.  It  is 
a fact,  however,  that  although  the  fundamental  character  of  both 
maladies  remains  unaltered,  90  per  cent,  of  hysterical  subjects  are 
cured  of  those  more  classical  manifestations  that  form  the  morbid 
syndrome,  whilst  epilepsy  is  rarely  cured. 

In  my  practice,  which  now  extends  over  a considerable  period 
of  time,  I have  followed  up  the  history  of  ladies  treated  by  me  for 
grave  forms  of  hysteria,  and  have  found  that  subsequently  they 
became  irreproachable  wives  and  mothers. 

Therafy. — The  therapy  will  be  understood  from  what  we  have 
already  said  when  speaking  of  the  symptomatology  and  the  setiology 
of  hysteria. 

Girls  who  are  neuropathic,  emotive,  and  sensitive,  the  daughters 
of  hysterical  mothers,  should  be  brought  up  apart  from  the  family. 
The  upbringing  ought  to  be  kindly  but  strict,  with  no  uncertainties 
about  it  and  no  compromises.  It  must  be  straightforward  and 
sincere,  and  such  as  will  not  weary  the  mind,  but  keep  it  always 
within  the  confines  of  actual  reality.  There  must  be  no  sensational 
romances,  no  fantastic  tales,  and  no  exaggerated  mysticism. 
Only  so  much  religion  should  be  taught  as  will  assist  in  developing 
positive  morals,  and  no  more.  Methodical  muscular  exercises 
should  be  practised  to  raise  the  physical  tone  of  the  personality. 


HYSTERICAL  INSANITY  569 

Tonic  and  reconstituent  treatment  is  advisable,  with  hydrotherapy 
and  sea-bathing. 

It  is  a duty  to  separate  daughters  from  hysterical  mothers, 
whenever  possible,  and  girls  whose  minds  are  well  balanced  from 
a sister  who  is  hysterical. 

A close  watch  must  be  kept  upon  the  manifestations  of  the 
sexual  instinct,  and  upon  outbreaks  of  passion  against  companions  ; 
also  upon  the  possibility  of  precocious  and  unnatural  love,  which 
enervates  and  perverts. 

It  is  a good  rule  that  a neurotic  subject  of  this  category  should 
never  assist  in  sickness,  particularly  in  cases  of  accident  and  those 
that  excite  the  emotions.  Their  sufferings  should  be  duly  noted, 
but  on  no  account  magnified,  nor  should  any  undue  concern  be 
manifested  about  them.  Above  all,  the  medical  attendant  should 
not  suggest  anything  by  asking  the  patient  about  phenomena  that 
do  not  exist. 

When  the  malady  has  developed,  the  removal  of  the  sufferer 
from  her  surroundings  is  always  one  of  the  principal  means  of  cure. 
In  all  cases  the  doctor  must  exercise  great  authority,  but  that  need 
not  prevent  kindness.  It  must  not  be  forgotten  that  the  treatment 
is  suggestive,  and  that  the  suggestion  springs  from  his  wisdom, 
from  his  authority,  and  from  his  conviction.  No  drug  is  of  any 
use,  for  none  could  have  any  other  action  than  that  of  suggestion. 
No  drug  that  the  hysterical  subject  has  refused  will  act  efficaciously, 
except  perhaps  an  injection  of  morphine  in  states  of  superexcita- 
tion, in  which  case  the  physician  must  employ  it  with  due  restric- 
tions and  with  prudence. 

For  a long  time  back  I have  been  making  as  little  use  as  possible 
of  common  hypnotism,  for  I am  convinced  that  that  is  simply 
provoked  hysteria,  and  nothing  else,  and  I consider  it  both  hurtful 
and  dangerous  as  a means  of  treatment.  The  suggestion  ought  to 
spring  from  the  mind  of  a cultured  and  authoritative  medical  man, 
and  should  be  made  when  the  patient  is  awake.  When  words  do 
not  succeed,  certain  other  means  of  impression,  such  as  electricity, 
and  especially  static  electricity,  may  meet  with  success.  The  dis- 
charge of  large  sparks  simultaneously  with  commands  is  very  often 
efficacious  with  regard  to  the  signs  of  hysteria,  on  the  disappearance 
of  which  the  personality  is  reconstituted.  According  to  the  case, 
there  will  remain  latent  hysteria  in  its  various  forms,  but  compatible 
with  family  and  social  life. 


CHAPTER  VIII 

PARANOIA 

This  is  a psychosis  constituted  essentially  of  a disturbance  that  is 
mainly  intellectual,  and  through  which  the  personality  undergoes 
a slow  transformation  in  its  relations  with  the  outside  world.  This 
metabolism  of  the  personality  is  induced  by  false  products  of  thought, 
which,  although  the  logical  process  in  the  structure  of  thought  is 
preserved  unharmed,  are  assumed  to  be  real,  thus  giving  rise  to 
alterations  in  the  relations  of  the  individual  with  his  environment. 
The  false  products  of  thought,  or  the  ideas  of  delirium,  are  not 
primary,  as  Westphal  and  Cramer  thought.  They  have  their  root 
in  the  emotive  nucleus  of  the  personality  itself,  and  they  are  de- 
veloped according  to  the  inexorable  law  of  association  between 
emotion  and  thought.  It  is  certain  that  when  a man  accepts  as  a 
reality  a false  product  cf  his  own  thought,  the  very  fact  of  his 
doing  so  compels  us  to  admit  that  there  is  a great  anomaly  in  the 
formative  process  of  thought  and  a serious  defect  of  judgment; 
the  mechanism  of  thought  is  subjugated  by  the  emotions  and 
the  sentiments  that  are  morbidly  predominant.  The  abnormal 
emotive  state,  for  reasons  that  are  quite  individual,  either  alters 
the  process  of  synthesis  in  the  formation  of  thought,  so  that  the 
delirium  appears  to  be  primary,  and  not  assisted,  at  least  in  the 
beginning,  by  sensory  disorders,  or  it  alters  primarily  the  percep- 
tive process,  giving  rise  to  illusions  and  hallucinations  (see  Part  IT), 
and  through  the  abnormal  products  of  the  perceptive  sphere  deliria 
are  formed.  The  false  ideas  originated  in  this  way  (deliria),  become 
assimilated  with  the  conditions  of  the  consciousness,  to  which  they 
lend  their  tone,  and  an  emotive  and  determinative  character 
peculiarly  their  own.  Those  which  are  endowed  with  strong 
assimilative  power  induce  a metabolic  process,  sometimes  rapid, 
but  more  frequently  slow,  either  total  or  partial,  restricted  to  the 
present  or  retrospective  of  the  whole  intellectual  patrimony  of  the 
personality,  and  they  impress  on  the  sensory  function -on  the  one 
hand  and  on  the  perceptive  function  on  the  other  the  work  that 
serves  for  their  further  development,  disintegrating  the  old  per- 

570 


PARANOIA 


571 


sonality  and  reconstructing  a new  personality  of  which  they  them- 
selves are  the  essence. 

We  have  said  that  false  ideas,  which  are  the  outstanding  feature 
of  the  psychosis  that  we  are  now  dealing  with,  emanate  from  the 
emotive  nucleus  of  the  personality.  The  old  supposition  of  Krafft- 
Ebing  and  Meynert,  maintained  also  by  some  alienists  in  recent 
times,  that  these  deliria  are  independent  of  an  affective  condition 
of  the  mind,  is  no  longer  tenable  in  view  of  modern  criticism  (see 
Part  II.),  and  must  be  restricted  solely  to  the  signihcation  that 
paranoic  deliria  are  independent  of  maniacal  exaltation  and  of 
melancholic  depression.  In  all  the  better  known  and  better 
studied  forms  of  paranoia  the  emotions  are  the  fundamental  and 
primary  fact. 

It  is  the  emotions  that  give  the  tone  to  the  personality,  and  this 
idea,  which  I have  been  developing  for  many  years  in  my  clinical 
lectures,  is  also  found  in  the  publications  of  Grimaldi  and  of  Del 
Greco,  while  it  has  been  fully  developed  by  the  school  of  Tam- 
burini,  particularly  by  Ferrari  (‘  Influenza  delle  emozioni  sulla 
genesi  e lo  sviluppo  dei  delifiif  etc.,  Riv.  Sper.  di  Fren.,  1901). 

In  paranoia  the  fundamental  emotions,  which  are  also  an  expres- 
sion of  the  altered  kinaesthesis,  are  emotions  of  a primitive  character, 
such  as  suspicion,  vanity,  pride,  and  fear — fear  of  injury  and  destruc- 
tion, desire  of  exaltation  and  of  grandeur  of  one’s  own  ego.  Therein 
lies  the  reason  of  the  egocentric  attitude  of  the  paranoic  subject 
(Specht) . These  primitive  emotive  states,  intrinsic  to  the  personality 
and  proportioned  differently  in  different  men,  determine  currents  and 
orders  of  ideas  and  actions  in  the  evolution  of  the  personality, 
which  succeed,  in  various  ways,  in  protecting  or  expanding  the  per- 
sonality in  a rigorously  logical  fashion.  When  those  emotive  states 
exceed  the  normal  measure  in  intensity  and  persistence,  they  exer- 
cise an  absolute  dominion  over  the  consciousness,  until,  through 
their  having  once  assumed  government  over  the  senses  and  the 
intellect,  there  is  an  alteration  of  the  perceptive  and  the  appercep- 
tive processes  that  insure  normal  relations  between  the  individual 
and  his  environment. 

The  evidence  of  the  facts  goes  to  prove  that  these  emotions  are 
not  evolved.  Their  prevalence  proves  a defect  in  the  evolution  of 
the  personality,  in  which  there  is  lacking  that  degree  of  appercep- 
tive power  that  is  the  surest  guarantee  of  a due  adaptation  of  the 
individual  to  his  environment. 

Paranoic  deliria  are,  therefore,  not  autochthonous  ideas,  but  of 
emotional  origin.  The  emotional  character  of  the  malady  is  fre- 
quently lost,  just  in  proportion  as  the  delirious  ideas  become  con- 
crete, affirm  themselves,  and  assimilate  the  most  adaptable  part  of 
the  content  of  the  personality.  When  we  find  an  occasion  to  follow 
out  the  evolution  of  a personality,  first  in  the  state  of  sanity,  and 
then  from  the  moment  that  it  begins  to  bend  and  take  a paranoic 


572 


PSYCHIATRY 


direction,  we  acquire  conviction  that  the  idea  of  the  delirium  does 
not  rise  in  the  consciousness  per  se,  is  not  a fungus,  certainly  not 
an  embryonic  element  that  has  perchance  found  its  way  into  the 
structure  of  the  personality.  It  is  not  preformed,  like  those  em- 
bryonic cells  that  have  not  undergone  the  normal  metamorphosis 
into  specific  tissue,  but  have  remained  entangled  in  the  tissues, 
while  their  destiny  is  to  become  a canker  or  sarcoma  when  the 
moment  arrives.  This  canker  or  sarcoma  in  its  evolution  invades 
the  organ  in  which  it  is  developed,  and  transforms  it  more  or  less 
rapidly,  just  as  paranoic  delirium  does  with  the  sane  personality. 

The  fundamental  emotions  that  prepare  the  ground  for  paranoic 
delirious  ideas  are  attributes  of  man  in  his  social  aspect — suspicion, 
ambition,  love.  The  fear  of  hurt  to  all  that  forms  part  of  the  ego, 
intrinsic  or  extrinsic,  all  that  reflects  one’s  own  personality  or  what 
one  possesses,  is  in  inverse  proportion  to  the  psychic  vigour,  and 
especially  to  the  power  of  apperception  of  the  social  relations.  Am- 
bitious aspirations  towards  the  exaltation  of  one’s  own  personality 
form  the  mystic  dream  of  adolescence,  when  the  troubled  spirit,  in 
its  abstraction  from  a reality  that  it  does  not  yet  understand, 
abandons  itself  unconsciously  to  the  waves  of  fancy,  and,  plunging 
into  a dream-world  of  joys,  of  power  and  of  riches,  is  fascinated  by 
what  it  finds  there.  Then  the  subject,  who  lacks  one  or  other  of  the 
intrinsic  or  extrinsic  elements,  physical  or  psychic,  individual  or 
social,  required  for  the  realization  of  his  dreams,  finally  mistakes  the 
dream  for  reality,  and  becomes  a confirmed  believer  in  the  world 
of  chimeras. 

These  three  emotions — suspicion,  ambition,  and  love — give  the 
three  classic  forms  of  paranoia  : the  persecutory,  the  ambitious  or 
proud,  and  the  erotic. 

The  defect  of  evolution  that  characterizes  those  individuals  who 
are  attacked  consists  precisely  in  the  prevailing  tone  of  a primitive 
emotion,  not  duly  evolved,  in  association  with  a defect,  original  or 
acquired,  of  the  apperception  of  the  relations  of  the  individual  to 
reality.  The  suspicious  person  who  surrounds  himself  with  pre- 
cautions in  order  not  to  fall  into  the  net  that  his  adversaries  spread 
for  him,  thus  clearing  the  way  for  his  advance,  and  the  ambitious 
subject,  who  sees  his  objective,  and  to  attain  it  disposes  to  the  best 
advantage  his  own  powers  and  all  the  means  that  he  can  command, 
may  be,  and  in  most  cases  are,  strong  and  victorious  in  the  struggle 
for  existence.  The  paranoic  subject,  on  the  other  hand,  is  a weak 
person,  who  by  his  mode  of  thinking  and  feeling  is  driven  into  the 
world  of  chimeras,  on  which  he  expends  all  the  power  of  his  logic, 
and  from  which  he  is  incapable  of  drawing  back,  and  so  reconciling 
himself  with  reality. 

As  will  easily  be  seen  from  the  foregoing,  in  none  of  its  forms 
has  paranoia  any  atavistic  character,  according  to  the  doctrine 
maintained  so  brilliantly  by  Riva  and  by  Tanzi,  following  what 


PARANOIA 


573 


Lombroso  has  said  with  regard  to  the  analogy  between  the  nature 
of  crime  and  the  criminal.  The  intellectual  content  of  paranoia  is 
nourished  by  the  life  of  the  environment,  advances  with  the  subject 
through  the  various  stages  of  his  evolution,  and  changes  only  in  so 
far  as  the  object  of  fear  and  of  human  ambition  changes  with  the 
progress  of  thought.  In  ancient  times  gods  and  evil  spirits  inspired 
this  fear.  The  relentless  struggle  for  existence,  altogether  a feature 
of  modern  times,  has  impressed  a new  character  on  the  delirium 
of  the  present  day.  In  a lecture  forming  part  of  a course  on 
psychiatry  delivered  at  the  University  of  Palermo  I said  ; 

‘ The  spirit  of  modern  times,  as  displayed  even  in  the  genial 
work  of  Manzoni,  in  which  religion  becomes  again  a consciousness 
of  one’s  own  duty  and  of  resignation,  and  human  persecution  is 
substituted  for  the  persecution  of  evil  spirits,  has  insinuated  itself 
into  the  public  consciousness  ; and,  with  the  struggle  for  existence, 
in  which  all  are  called  to  take  part,  fully  revealed,  that  spirit  gives 
the  key  to  the  deliria  of  modern  society.  This  struggle,  in  which 
only  human  resistance,  human  difficulties,  and  human  enemies  are 
met  with,  and  in  which  the  exalted  aspirations  of  the  weak  are 
broken  against  the  bulwarks  of  the  strong  and  of  the  astute,  leaves 
in  its  track  an  endless  number  of  fallen  victims,  who,  too  weak  or 
crushed  in  the  lost  battle  of  life,  pass  the  bounds  of  the  domains  of 
psychiatry,  and  live  amid  “ the  unconscious  ” on  what  once  formed 
the  subject  of  their  dreams  or  their  fears — viz.,  visions  of  wealth 
and  thoughts  of  bitter  enemies — that  is  to  say,  on  the  delirium  of 
grandeur  and  the  delirium  of  persecution  ’ (‘  Gli  orizzonti  della 
Psichiatria^  La  Psichiatria,  etc.,  1899). 

In  1893  Magnan  expressed  this  same  idea  {Legons  cliniques  sur 
les  maladies  mentales)  : 

‘ We  know,’  he  writes,  ‘ the  general  characteristics  and  mode  of 
evolution  of  the  chronic  delirium,  but  the  aspects  under  which  the 
patient  presents  himself  vary  with  his  religion,  his  beliefs,  his  educa- 
tion, the  social  environment  in  which  he  lives,  and  his  preoccupa- 
tions. From  these  diverse  elements  he  draws  what  he  requires  to 
form  his  delirium,  and  give  it  a special  character.  On  one  side  we 
see  the  delirium  of  the  Middle  Ages,  with  its  superstitious  beliefs, 
and  on  the  other,  the  modern  delirium  that  utilizes  the  progress  of 
science  and  of  industry  in  connection  with  political  struggles  and 
with  the  new  social  organization.  Towards  the  close  of  the  Middle 
Ages  and  at  the  period  of  the  Renaissance  men  spoke  of  witch- 
craft, of  evil  spirits,  of  obsession  and  possession  by  devils,  and  the 
delirium  was  nothing  else  than  the  reflection  of  those  beliefs  and 
of  those  prejudices  which  ignorance  rendered  still  more  profound. 
At  the  end  of  the  eighteenth  century  mesmerism  and  the  magnetic 
fluid,  just  like  spiritualism  later  on,  with  its  invocations  of  spirits 
and  turning  of  tables,  served  the  persecuted  subjects  with  an 
explanation  of  their  morbid  sensations.  To-day  political  struggles. 


574 


PSYCHIATRY 


the  great  forces  of  Nature,  and  the  numerous  applications  of  physical 
and  chemical  agents,  magnetism,  suggestion,  microbes,  and  the 
great  political  societies,  have  replaced  the  marvellous,  attract 
universal  attention,  and  become  the  point  of  origin  of  delirious 
ideas.’ 

Of  course,  it  is  true  that  even  to-day  we  meet  with  paranoic 
deliria  of  religious  content,  such  as  melancholic  deliria  of  obsession 
by  demons,  or  of  sudden  bewitchment,  etc.  ; but  there  is  no  neces- 
sity to  fall  back  on  a theory  of  atavism  to  explain  the  origin  of 
these.  These  beliefs  still  exist  among  our  people.  Education  and 
social  progress  have  succeeded  in  freeing  the  minds  of  a certain 
class  from  these  ideas,  perhaps  the  most  select  class  in  the  civil 
world,  but  people  in  the  lowest  strata  still  live  under  the  influ- 
ence of  these  beliefs ; and  even  men  who  have  reached  a high  level 
of  culture  and  of  mental  evolution  have  imbibed  the  same  ideas 
and  the  same  beliefs  during  their  childhood,  in  their  domestic 
circles  or  amongst  the  people. 

These  are  survivals  from  the  Middle  Ages.  Human  evolution 
is  slow,  and  primitive  characteristics  have  not  yet  disappeared  from 
mankind.  Why,  then,  have  recourse  to  a theory  of  atavism  ? 
Everything  that  the  paranoiac  (and  the  same  may  be  said  of  all 
delirious  subjects)  manifests  in  his  delirium  is  found  in  his  actual 
environment,  or  in  another  environment  in  which  he  lived  at  one 
period  of  his  life,  and  which  now  forms  an  internal  or  mental  en- 
vironment, so  that  all  that  remains  is  the  exaggeration  of  the 
fundamental  emotiveness  and  the  insufficiency  of  the  power  of 
apperception  of  the  relations  of  the  individual  to  his  environ- 
ment. 

These  two  fundamental  facts  may  manifest  themselves  at  an 
early  age,  before  the  personality  has  been  completely  evolved,  and 
in  such  a case  we  may  speak  of  developmental  primary  paranoia ; 
or  they  may  appear  in  mature  age,  when  the  struggle  for  existence 
is  keener,  and  when  the  obstacles  in  the  way  of  the  realization  of 
one’s  desires  in  life  are  greater,  while  the  ambition  is  also  greater, 
and  in  this  case  we  speak  of  late  primary  paranoia.  The  latter, 
however,  may  be  distinctly  founded  on  a paranoic  character  ex- 
hibiting suspicion,  ambition,  asceticism,  etc.,  and  then  we  say  that 
we  have  a form  that  is  clearly  degenerative — that  is  to  say,  due  to 
defective  development  ; or  we  may  have  an  acquired  form  in  indi- 
viduals who  had  no  reason  to  manifest  any  of  those  features  that  mark 
the  paranoic  character  (which  might  be  considered  as  rudimentary 
developmental  paranoia),  and  this  we  shall  call  acquired  paranoia 
(ordinarily  neurasthenic).  This  last,  as  it  is  of  toxic  origin  (auto- 
toxic), and  develops  in  individuals  of  good  mental  constitution,  is 
placed  in  the  second  group. 

The  existence  of  a systematized  delirium,  whatever  its  content 
may  be,  does  not  warrant  us  in  recognising  paranoia  in  all  cases. 


PARANOIA 


575 


We  meet  with  systematized  delirium  as  an  epiphenomenon  or  as  an 
episode  in  various  maladies.  True  paranoia,  with  which  we  are 
now  dealing,  is  a constitutional  malady  that  has  its  foundation  in 
an  anomalous  psychopathic  structure,  generally  developmental,  and 
it  is  evolved  in  many  cases  on  a fixed  method,  with  a certain  suc- 
cession of  facts,  which,  in  their  historic  totality,  give  to  the  paranoia 
an  aspect  that  is  perfectly  recognisable. 

In  paranoia  all  the  representations  that  have  not  been  altered 
morbidly  have  regular  relations  among  themselves  (Mendel),  the 
logical  process  and  the  syllogistic  power  of  the  intelligence  being 
always  preserved ; but  the  power  of  verifying  and  controlling  the 
reason  is  lost,  and  thenceforth  the  senses  obey  false  premises. 
This  condition  of  affairs  is  represented  by  Robinovitch  in  a 
metaphor  when  he  writes  that  the  intellectual  apparatus  of  the 
paranoic  subject  is  to  a certain  degree  comparable  to  a good  flour- 
mill, which,  instead  of  grinding  grain,  grinds  stones  {Des  varietes 
cliniques  de  la  folie  en  France  et  en  Allemagne,  1896).  In  this  case 
the  stones  represent  the  predominance  of  a fundamental  emotion 
not  corrected  by  a sound  judgment — an  emotion  that  determines  a 
current  of  thought  unrelated  to  reality. 

It  is  not  to  be  wondered  at  if  in  all  countries,  at  a certain  stage 
of  the  evolution  of  the  people,  we  find  the  same  paranoic  deliria — 
the  primordAal  deliria  of  Griesinger.  The  theory  of  myths  is  not 
applicable  to  these  deliria,  nor  can  they  be  considered  as  effects 
of  a process  localized  in  a given  region  of  the  brain,  as  Krafft-Ebing 
supposes.  This  last  supposition  has  no  solid  foundation. 

The  reason  of  a certain  uniformity  that  exists  in  paranoia  in  all 
countries  will  be  found  in  the  emotive  origin  of  paranoic  deliria, 
and  in  the  emotions  themselves  that  provoke  those  deliria.  The 
desire  for  greatness  and  pleasure,  and  the  fear  of  being  deprived  of 
these,  are  fundamental  and  universal  emotions.  The  lack  of 
moderation  in  the  desire  and  the  fear,  and  the  return  to  a great 
extent  of  the  ego  of  childhood  (Meynert,  Del  Greco),  as  the  result 
of  disaggregation  of  the  personality,  afford  the  explanation  of  the 
phenomenon. 

All  that  is  atavistic  in  the  paranoic  subject  who  superimposes 
infantile  personality  on  the  adult,  thus  bringing  the  old  ego  into 
active  life,  in  coexistence  with  the  new  ego  (Schfile,  Seglas),  is  the 
disposition  to  present,  as  a result  of  impressions,  the  fact  of  a 
distinct  and  hostile  intelligence  (Del  Greco,  ‘ Sulla  evoluzione  del 
delirio  paranoico,'  Manicomio  Moderno,  1897-98). 

This  holds  for  the  delirium  of  persecution. 

From  the  group  of  paranoias  we  rigidly  exclude  all  those  syste- 
matized deliria  consequent  upon  other  psychoses,  the  so-called 
Wahnsinn  of  the  Germans.  These  systematized  deliria,  accom- 
panied by  recomposition  into  a new  personality  of  logical  aspect, 
follow  on  melancholia  and  hallucinatory  insanity  (Group  II.  of  our 


576 


PSYCHIATRY 


classification).  In  these  states  we  have  systematized  deliria  that 
are  secondary,  and  that  have  taken  root  in  a soil  exhausted  by  the 
primary  malady — that  is  to  say,  in  mental  enfeeblement. 

Further,  it  is  necessary  to  exclude  from  the  group  of  paranoias 
all  those  states  of  confusion  and  of  hallucination,  acute  or  sub- 
acute, such  as  the  amentia  of  Meynert,  acute  sensory  delirium,  and 
the  delirium  of  collapse,  which  Binswanger  thought  right  to  include 
in  the  group,  although  certainly  at  the  expense  of  clearness.  All 
these  syndromes  have  nothing  to  do  with  chronic  paranoia,  the 
subject  that  occupies  our  attention  here.  The  acute  or  subacute 
sensory  forms  belong  to  a group  with  which  we  shall  deal  in  another 
chapter.  In  this  regard  I am  in  accord  with  Sciamanna  and  with 
Tanzi  and  Riva,  who  consider  s^^stematized  delirium  as  a sympto- 
matic group,  whilst  true  paranoia  is  believed  by  these  two  authors 
to  be  a constitutional  malady  distinguishable  by  its  degenerative 
origin,  and  by  the  course  it  takes  (Tanzi  and  Riva,  La  Paranoia, 
etc.,  Reggio-Emilia,  1886). 

Secondary  paranoia  always  has  a basis  of  mental  decadence 
(Tonnini),  and  therefore  cannot  be  confused  with  primary  paranoia. 
In  hallucinatory  confusion  the  presence  of  an  apparently  syste- 
matized delirium  depends  upon  the  individual  temperament,  and 
upon  the  predominance  of  certain  hallucinations  ; but  even  these 
forms  cannot  be  confused  with  primary  paranoia. 

On  the  other  hand,  we  include  among  the  forms  of  paranoia 
those  that  develop  at  a late  period  in  individuals  who  have  been 
cured  of  a simple  psychosis,  such  as  melancholia  or  a sensory  delirium. 
Wernicke  also  recognises,  in  a certain  number  of  paranoias,  the 
after-effects  of  an  attack  of  acute  insanity,  and  particularly  of 
acute  hallucinatory  psychosis  (Die  Paranoische  Zustande,  Leipzig, 
1896).  This  is  a view  we  held  thirteen  years  ago  (Lojacono),  and 
it  is  certainly  accurate.  In  these  cases,  which  are  not  at  all  infre- 
quent, the  primary  psychosis  aggravates  the  hereditary  weakness, 
and  after  recovery  the  brain  is  left  more  vulnerable  than  before, 
whilst  at  the  same  time  there  remain  in  ‘the  unconscious’  residua 
that  prepare  the  way  for  the  paranoic  tone  of  mind. 

It  is  upon  this  soil  that  paranoia  is  developed  later  on,  and  such 
paranoia  we  may  consider  to  be  primary,  although  it  has  a genetic 
relation  with  the  preceding  psychosis. 

The  chronic  delirium  of  Magnan,  with  constant  cr  almost  con- 
stant evolution,  is  one  of  the  forms  of  paranoia  that  we  shall  dis- 
cuss. 

On  the  other  hand,  seeing  that  emotion  acts,  in  accordance  with 
the  condition  of  each  individual  person,  sometimes  directly  upon 
the  thought  and  the  process  of  synthesis,  at  other  times  upon  the 
sensory  field,  it  is  clear  that  we  may  have  simple  intellectual  paranoia 
and  also  hallucinatory  paranoia.  We  term  the  paranoia  halluci- 
natory when  the  hallucinations  provoked  by  emotive  tension  of  the 


PARANOIA 


577 


mind  are  of  uniform  content,  and  determine  a paranoic  current  of 
thought — that  is  to  say,  the  hallucinations  do  not  affect  the  logical 
power,  and  do  not  induce  confusion. 

In  the  development  of  paranoia  many  authors  recognise  four 
stages  : 

1.  The  prodromal  stage — the  period  of  inquietude,  or  of  subjec- 
tive analysis  according  to  some  other  authors. 

2.  The  stage  of  ideas  of  persecution. 

3.  The  stage  of  ideas  of  grandeur — the  period  of  transformation 
of  the  personality,  according  to  Regis  and  others. 

4.  The  stage  of  mental  enfeeblement  or  pseudo-dementia. 

According  to  these  stages  in  the  evolution  of  paranoic  deliria, 

it  would  appear  that  the  deliria  of  grandeur  are  always  comple- 
mentary to  the  deliria  of  persecution.  Daily  observation,  how- 
ever, proves  that  the  delirium  of  grandeur  is  complementary  to 
that  of  persecution  in  virtue  of  the  same  law  by  which  the  delirium 
of  persecution  is  sometimes  complementary  to  the  delirium  of 
grandeur.  Paranoia  emanating  from  two  fundamental  emotions 
develops,  by  the  action  of  factors  special  to  each  individual,  either 
as  paranoia  of  persecution  or  as  paranoia  of  grandeur,  in  the  first 
instance,  and  the  complementary  delirium  may,  or  may  not,  sub- 
sequently associate  itself  with  the  primary  delirium. 

There  are  cases  of  paranoic  deliria  of  persecution  and  of  grandeur 
that  are  never  complicated  by  complementary  deliria,  no  matter 
how  long  they  may  last. 

Some  of  these  deliria  do  not  follow  a regular  process  of  evolu- 
tion, nor  do  they  present  the  phases  above  mentioned.  They  run 
an  irregular  course,  and  vary  in  content,  or  they  show  phases  of 
improvement. 

I consider  it  nearer  to  the  truth  to  divide  the  evolution  of 
paranoia,  or  the  ‘ systematized  progressive  insanity  ’ of  the  French, 
into  three  periods  : 

1.  The  prodromal  period. 

2.  The  period  of  efflorescence  of  the  delirium,  primary  and  com- 
plementary, when  there  is  a complementary  delirium. 

3.  Mental  decadence. 

From  what  has  hitherto  been  said,  we  are  enabled  to  distinguish : 

1.  The  paranoic  character  (rudimentary  paranoia). 

2.  Developmental  paranoia,  manifesting  itself  from  the  period 
of  adolescence,  or  even  earlier  (Sander). 

3.  Late  paranoia,  developing  upon  a paranoic  character  that  is 
but  slightly  accentuated  or  even  latent. 

4.  Acquired  late  paranoia,  developing  upon  a normal  constitu- 
tion. This  form,  however,  may,  at  least  in  a good  number  of  cases, 
be  placed  in  the  second  group  of  our  classification,  along  with  acute 
paranoia. 

Late  paranoia  can  be  distinguished  as  : {a)  simple — that  is,  with- 

37 


578 


PSYCHIATRY 


out  complementary  delirium  ; {h)  complicated — that  is,  with  com- 
plementary delirium. 

Both  late  and  developmental  paranoia  are  further  distinguished 
as  intellectual  and  hallucinatory.  The  intellectual  form  commences 
and  continues,  for  some  time  at  least,  without  hallucinations,  whilst 
the  hallucinatory  form  commences  with  hallucinations. 

The  delirium  of  grandeur  is  primary  much  more  frequently  than 
is  generally  believed,  and  it  completes  its  evolution  without  always  | 
giving  place  to  delirium  of  persecution,  or  the  latter  may  appear  | 
only  at  a late  stage.  In  Part  II.  of  this  work  I have  related  the 
case  of  Caporali,  a poor  tailor  who  dreamt  of  raising  the  economic 
condition  of  his  district,  and  threw  stones  at  Crispi,  who  was  then 
President  of  the  Council  of  Ministers.  Here  I quote  a portion  of  a 
very  long  letter  addressed  to  me  by  a patient  in  a fairly  good  posi- 
tion and  of  some  education,  who  had  proved  despotic  and  undis- 
ciplined from  his  childhood,  both  in  his  own  family  and  in  boarding- 
schools,  from  which  he  was  expelled.  In  i88i  Professor  Virgilio 
found  that  he  was  affected  by  megalomaniacal  paranoia,  and  a few 
years  later  he  became  a subject  of  study  in  the  Provincial  Asylum 
of  Naples. 

Observation  XIV.— This  patient  belonged  to  a neuropathic  family,  . 
but  did  not  present  any  anthropological  degenerative  stigmata,  nor  any  , 
functional  disturbances.  He  sent  me  a letter  of  130  pages  to  let  me  ; 
know  who  he  was.  From  the  few  quotations  that  I reproduce  here  we  ' 
can  reconstruct  his  psychic  personality,  and  trace  the  developmental  , 
disturbance  in  the  form  of  paranoia  superba.  \ 

‘ You  must  know  in  the  first  place,  Professor  Bianchi,  that  when  I ' 
was  born  in  1851  my  parents  were  expecting  a girl,  and  it  was  their  disap- 
pointment in  the  sex  that  they  had  expected,  and  that  did  not  arrive, 
that  first  determined  the  character  of  my  tempestuous  existence. 

‘ I consider  it  useless  to  add  or  to  prove  here  that  I was  not  responsible  ? 
for  this  first  family  discord  provoked  by  my  birth  on  the  evening  of  ^ 
December  23,  1851 — a discord  that  was  to  prepare  for  me  a life  of  such  | 
agitation  ; for,  as  it  was  not  in  my  power  to  transform  myself  into  a girl, 

I had  to  yield  to  the  embraces  of  my  parents  and  be  born  a boy,  and  all  | 
that  I need  say  here  is  that  from  my  mother  I inherited  extreme  sensitive-  , 
ness.  From  my  earliest  years  this  sensitiveness  was  the  torture  of  that 
part  of  my  life  that  I am  now  relating  to  you.  In  fact,  had  I been  born 
less  sensitive,  I should  not  have  been  able  from  my  very  infancy  to  be 
conscious  of  the  want  of  concord  that  estranged  me  from  the  environment 
in  which  I was  born  ; and  had  I not  felt  that  want  of  concord,  I should 
have  experienced  no  mistrust ; and  in  the  absence  of  mistrust  I should 
not  have  detached  myself  still  further  from  my  parents  in  our  common, 
relations  ; and  had  I not  detached  myself  still  more,  the  lapse  of  years 
and  our  common  good  dispositions  would  probably  have  removed  the 
disappointment  on  the  question  of  sex,  to  the  satisfaction  of  both  parties  : 
for  if  my  parents  had  tolerated  me,  and  had  I identified  myself  with  their 
desires,  sinking  everything  in  one  single  thought,  the  discord  arising  from 
my  birth  might  have  been  removed  by  the  concord  of  my  life.  That 
concord  was  never  reached,  because,  as  I came  to  understand  the  matter  too 
soon,  and  could  very  little  tolerate  the  state  of  affairs,  I entrenched  myself  in 
the  idea  of  maintaining  my  ow)i  individuality  at  whatever  cost,  for  I. 


PARANOIA 


579 


would  not  have  my  individuality  sacrificed  to  a misunderstanding,  for 
which  I felt  I was  irresponsible.  If  my  parents  chose  the  wrong  time  for 
procreation,  it  did  not  follow  that  I ought  to  sacrifice  my  days  because 
of  the  mistake  of  my  being  procreated  in  absolute  ignorance  of  “ came  and 
effect.”  Therein  is  involved  a social  science  that  ought  to  form  one  of  the 
bases  of  the  reform  that  I desire,  and  for  its  practical  development  we  must 
have  reformatory  asylums,  arranged  to  compensate  the  very  strange 
metamorphoses  of  social  conditions,  which  destroy  all  order  in  the  presence 
of  humanity.  That  is  why,  as  my  origin  was  a very  painful  one,  I have 
always  been  able  to  keep  to  a fixed  determination  to  do  one  thing  rather 
than  another ; for  ever  since  my  most  tender  years  it  has  been  my  exclusive 
idea  not  to  allow  myself  to  be  overmastered  by  the  dispositions  of  those  who, 
having  got  me  when  they  did  not  wish  me,  might  agree  together  to  dispose  of 
me  without  my  knowledge. 

‘ As  you  will  clearly  see,  it  was  my  individuality  that  was  asserting 
itself,  and  it  was  an  individuality  that  was  neither  erroneous  nor  blame- 
worthy, because,  if  we  are  to  contribute  to  the  end  of  the  true  well-being  of 
humanity,  it  is  necessary  for  the  growth  and  development  of  our  offspring  that 
they  should  not  confound  their  proper  and  essential  characteristics  with  the 
temporary  character  of  their  procreators,  identifying  themselves  totally  with 
the  succession  of  the  same.,  so  that  after  the  space  of  nineteen  centuries 
we  find  ourselves  developed,  simply  through  certain  improvements  that 
are  the  exclusive  product  of  the  scientific,  literary,  and  artistic  spirit.  In 
point  of  principle,  however,  the  best  Christians  of  the  present  day  corre- 
spond exactly  to  the  Hebrews  of  the  ancient  Law,  except  as  regards  those 
formalities  that  the  action  of  Christ  drove  out  of  the  Temple  of  Jerusalem 
and  that  have  been  reconstituted  in  a different  form  in  the  Church  of 
Rome,  which,  taking  into  itself  all  the  evil  of  the  old  system,  and  patching 
up  the  worst  in  the  wounds  of  the  dead  Redeemer,  has  drawn  from  the  fusion 
of  the  Old  with  the  New  Testament  the  paradox  of  a form  that  can  be  adapted 
to  meet  all  requirements. 

‘ In  speaking  in  this  way,  I have  no  intention  to  refer  to  the  Christianity 
professed  by  my  parents,  who  are  debased  in  my  sight  by  the  simple  fact 
that  principles  have  been  maliciovisly  falsified  in  their  minds — a result 
that  plainly  accrues  from  the  marriage  of  the  old  with  the  new,  an  evil 
result  which,  even  after  nineteen  centuries  of  Christianity,  has  not  yet 
been  circumscribed  and  brought  into  harmony  with  the  just  requirements 
of  the  new  Society,  which,  rather  than  yield  to  an  impure  Christianity,  is 
desperately  opposing  the  ministers  of  imposture,  and,  in  its  endeavours  to 
get  rid  of  the  impurity  of  those  in  power,  sometimes  makes  mistakes  in 
distinction,  often  violating  the  purity  of  its  Founder.  That  is  the  reason 
why  I was  incarnated  in  the  new  blood,  and,  through  the  force  of  my  precocious 
intelligence,  I avoided  confounding  my  infantile  theories  with  the  hallucina- 
tions of  those  about  me,  so  that  from  my  infancy  I was  condemned  to 
struggle  in  order  to  maintain  my  individuality,  which  was  threatened  by 
the  vicissitudes  that  had  preceded  my  birth.  Raised  upon  the  pedestal 
of  thirty  years’  experience,  in  i88i  I was  able  to  swallow  the  bait  held  out 
to  me  by  Professor  V.  You  will  understand  the  intrigue.  Anticipate 
me,  therefore,  in  divining  its  consequences,  arguing  these  from  the  hostile 
reception  I met  with  within  the  domestic  walls  in  1851,  when  I made  my 
first  appearance  in  the  home,  being  really  responsible  for  the  misunder- 
standing that  then  arose,  and  that  still  exists,  between  my  parents  and 
me  ; whilst  in  1864  this  misunderstanding,  when  unmasked,  gave  my 
father  the  occasion  to  revenge  himself  on  me  for  the  mistake  in  a question 
of  responsibility  that  weighed  and  still  weighs  heavily  upon  him.  . . . 

‘ When  this  has  been  said,  what  more  would  you  have  me  say  ? 

^ ‘ I might  continue  in  order  to  satisfy  your  desire  completely,  but  at 
this  moment  such  a course  would  be  ridiculous  were  it  spontaneous, 

37—2 


58o 


PSYCHIATRY 


whilst  it  would  be  an  act  of  violence  were  you  to  demand  it  from  me. 
And,  really,  who  am  I that  speak  ? 

‘ According  to  the  Civil  Register  kept  in  the  Archives  of  C.,  I am  G.  S., 
born  in  December,  1851,  of  parents  N.  and  A.  In  the  view  of  the  Depart- 
ment of  Public  Order,  represented  in  Caserta  by  the  Prefect  G.,  I am  a 
lunatic,  brought  before  the  Tribunal  of  the  Social  Conscience.  I am  one 
who  has  lost  his  way,  but  am  worthy  of  consideration  rather  than  of  mal- 
treatment ; in  the  eyes  of  humanity  ? . . . 

‘ If  I really  have  a mandate  to  fulfil  in  the  sight  of  humanity,  I do  not 
intend  to  sacrifice  my  name  and  my  paternity  to  my  mandate  ; and  if  I 
have  not  such  a mandate,  why  should  anyone  try  to  divert  me  from  that, 
and  to  give  me  the  lie  before  I have  proclaimed  myself  ?’ 

Later  on,  by  a gradual  but  continual  evolution  of  the  idea  of  his 
capacity,  he  formulates  his  delirium  more  fully,  but  without  a trace  of 
sensory  disorder.  Continuing  to  develop  a plan  of  internal  and  foreign 
political  action,  he  comes  to  the  following  conclusion  : 

‘ Further  than  that,  let  both  the  idea  of  an  Italian  Republic  and  the 
other  idea  of  the  return  of  the  Bourbons  be  abandoned,  if  you  will,  so  as 
to  calm  anxieties  and  popular  agitation,  the  groanings  of  a people  that 
desires  and  finds  not  what  it  desires,  the  will  of  a mass  witho^it  a head, 
that  writhes  about,  contorts  itself,  stretches  itself  out,  draws  hack  again, 
expends  its  breath,  and  does  nothing ; we  may  then  proceed  to  the  explicit 
affirmation  of  Italian  nationality.  We  must  absolutely  fight  and  conquer, 
and  in  the  present  state  of  European  affairs  we  should  have  much  sym- 
pathy if  we  were  to  attack  France,  while  certainly  we  should  come  out 
victors  if  foreign  politics  were  directed  by  a man  who  knew  how  to  prepare 
the  ground  properly. 

‘ Where  is  that  man  ? I see  him  not ; but,  had  he  not  been  disturbed 
in  1881  by  that  phrenologist  V.,  to-day  he  might  be  at  his  post.’ 

' In  this  patient  there  does  not  exist,  and  there  has  never  existed, 
any  trace  of  delirium  of  persecution,  if  we  except  the  resentment 
against  the  alienist  who  declared  him  insane  in  the  year  1881,  and 
against  his  father,  who  had  on  two  occasions  requested  and  obtained 
the  confinement  of  his  son,  first  in  the  Aversa  Asylum  and  after- 
wards in  the  asylum  of  Naples. 

Here  we  find  a lucidity  of  ideas  that  is  not  common,  arising  from 
the  consciousness  of  an  overdeveloped  personality,  proud,  but  with- 
out any  sensory  disturbance  (simple  intellectual  paranoia  with 
political  character,  the  ‘ political  delirium  ’ of  some  writers). 

Another  inmate,  among  many  whom  I have  observed,  addicted 
to  onanism  for  many  years,  conceived  the  design  of  releasing 
humanity  from  the  evils  that  afflict  it,  by  demonstrating  the  origin 
of  those  troubles.  According  to  him,  all  evil  results  from  the 
metamorphosis  of  the  sperm  of  onanists  into  evil  spirits.  The 
voluminous  work  that  he  wrote,  full  of  the  strangest  arguments, 
was  the  result  of  long  lucubrations,  for  the  writer  had  isolated 
himself  from  his  family,  and  shut  himselt  up  in  his  own  room, 
where  he  lived  a misanthrope,  in  order  to  elaborate  this  precious 
treatise.  When  it  was  completed,  he  even  resorted  to  violence  to 
get  possession  of  his  mother’s  money  in  order  to  publish  it,  alto- 
gether regardless  of  a sister  who  was  d}dng  of  tuberculosis,  and  so 
he  had  to  be  removed  to  an  asylum. 


PARANOIA 


581 


The  following  case  proves  how  the  circumstances  of  life  can 
determine  the  current  of  paranoic  thought  in  the  minds  of  those 
who  are  so  predisposed,  and  sow  a seed  that  germinates  slowly, 
doing  its  work  in  the  unconscious.  When  ‘ the  unconscious  ’ has  been 
filled  with  new  products,  then  a sensory  error  is  sufficient  to  give 
the  consciousness  a clear  notion  of  what  was  in  the  background, 
or  of  what  it  had  only  a hazy  idea.  This  is  a typical  case  of  primary 
paranoia  of  grandeur,  developed,  one  might  say,  under  our  eyes 
even  till  it  reached  the  degree  of  pseudo-dementia,  and  giving 
rise  at  a certain  stage  to  a rudimentary  delirium  of  persecution. 
The  most  important  feature  of  this  case  is  the  fact  that  the  original 
rudimentary  paranoia  of  grandeur  goes  back  to  the  early  youth  of 
the  subject.  It  was  strengthened  by  the  words  of  her  dying  mother, 
and  the  delirium  of  jealousy,  which  is  a form  of  the  delirium  of 
persecution,  was  only  an  acute  episode  that  interrupted  the  course 
of  the  evolution  of  a personality  clearly  and  developmentally 
megalomaniacal.  Here  is  the  case  : 

Observation  XV. — Long.  Raff.,  fu  Luigi,  forty- three  years  of  age,  of 
Castellamare  di  Stabia,  was  sent  to  the  asylum  of  Naples  on  February  27, 
1901,  because,  according  to  the  letter  that  accompanied  her,  she  was 
affected  with  delirium  of  jealousy.  More  than  two  years  before  she  had 
commenced  to  doubt  the  fidelity  of  the  man  with  whom  she  lived  in 
concubinage,  until  that  doubt  was  transformed  into  a delirium  of  furious 
jealousy,  with  all  the  train  of  phenomena  of  hallucination  and  illusion 
that  generally  accompany  delirium  of  that  sort. 

It  is  known  that  her  father  was  a gambler  and  a hard  drinker,  and 
that  he  died  suddenly,  after  having  dissipated  a moderate  fortune.  Her 
mother  died  at  forty-two,  probably  from  a cardiac  affection.  She  has 
only  one  sister  living  ; four  other  brothers  and  sisters  died  in  early  child- 
hood. When  a young  girl  she  suffered  from  enteric  fever,  but  after  that 
she  had  no  other  illness  worthy  of  note. 

She  was  brought  up  with  great  care  by  her  mother,  who  was  extremely 
fond  of  her.  On  her  deathbed  her  mother  gave  only  one  charge  to  her 
husband,  and  that  was  to  take  care  of  the  upbringing  of  this  daughter, 
who  might  have  a good  future,  because  she  was  beautiful  and  had  a lady- 
like manner  and  bearing,  as  though  she  had  been  horn  of  a princely  house. 
Our  subject  has  never  forgotten  those  words  of  her  mother,  and  after- 
wards, in  the  hydropathic  establishment  managed  by  her  father,  when 
she  saw  that  attention  was  paid  to  her  by  many  of  the  gentlemen  who 
came  there  for  treatment,  including  Prince  Tizio  and  the  Marquis  Cajo, 
she  began  to  ask  herself  whether  the  words  of  her  mother  were  not  really 
intended  to  be  a revelation.  It  seemed  to  her  almost  impossible  that  the 
daughter  of  L.  Long,  should  receive  attention  from  so  many  and  so 
elevated  personages.  The  doubt  as  to  her  real  origin  commenced  to 
dominate  her  mind  from  that  time  on  ; but  still,  because,  as  she  herself 
expressed  it,  she  had  a high  opinion  of  herself,  and  was  proudly  conscious 
of  her  dignity,  she  remained  content  with  the  modest  position  of  her 
family.  She  fell  in  love  with  a man  whom  she  now  declares  to  be  un- 
worthy of  her  affection  and  too  far  beneath  her  in  rank,  and  she  united 
herself  to  him,  with  no  other  bond  than  that  of  love.  Years  thus  passed 
in  comparative  tranquillity. 

As  she  advanced  in  age,  either  she  herself  came  to  understand  or 
else  her  relatives  pointed  out  to  her  the  irregularity  of  her  position. 


582 


PSYCHIATRY 


especially  with  respect  to  the  future  of  her  children,  and  she  demanded 
her  lover  should  marry  her.  When  the  latter  pointed  out  difficulties  in 
the  way,  she  supposed  that  he  had  carnal  relations  with  other  women, 
and  even  thought  that  he  was  married  to  someone  else.  Then  the 
delirium  of  jealousy  broke  out,  accompanied  by  corresponding  hallucina- 
tions. She  declared  that  she  had  seen  her  lover  in  the  arms  of  women  of 
all  sorts.  He  used,  she  said,  to  bring  them  to  her  house,  and  in  her 
presence  he  would  abandon  himself  to  shameless  acts  with  them.  Nothing 
else  was  talked  of  in  the  neighbourhood.  Her  lover’s  doings  formed  the 
subject  of  every  conversation.  Her  rivals  in  her  lover’s  affections  turned 
their  attention  wholly  upon  her  ; they  insulted  her,  and  did  everything 
possible  to  vex  her.  They  even  invented  a machine  to  drive  her  out  of 
her  lover’s  thoughts. 

In  such  a state  of  mind,  fired  by  jealousy,  troubled  upset  by 
hallucinations,  with  all  power  of  critical  judgment  lost,  she  could  no  longer 
put  any  restraint  upon  the  ideas  of  grandeur  that  had  been  germinating 
in  her  mund  from  her  early  youth.  Hitherto  these  had  been  only  vague 
and  suppressed,  but  now  they  took  the  form  of  a delirium  of  unbounded 
grandeur,  well  organized  and  developing  in  the  three  phases  of  beauty, 
riches,  and  high  birth,  but  more  especially  the  last.  As  we  have  seen, 
she  had  suspected  from  her  childhood  that  she  was  not  the  daughter  of 
L.  Long.  It  was  only  at  a very  much  later  date  and  through  a very 
strange  occurrence  that  she  decided  who  was  really  her  father.  One  day 
she  had  gone  to  visit  an  exhibition  of  waxworks,  and  she  was  much  struck 
when  she  observed  that  the  eyes  of  the  figure  which  she  was  told  repre- 
sented Napoleon  III.  were  fixed  upon  her  ; and  it  appeared  to  her  also 
that  the  chest  of  this  figure  heaved  with  emotion.  There  was  no  doubt 
that  the  spirit  of  Napoleon,  present  at  that  moment  in  the  wax  figure, 
was  much  moved  by  beholding  his  daughter  before  him.  From  that 
day  our  subject  has  had  the  conviction  that  she  is  the  daughter  of 
Napoleon  III.,  the  offspring  of  the  illegitimate  intercourse  of  the  French 
Emperor  with  a Countess  whose  name  she  does  not  know.  She  no  longer 
calls  herself  R.  Long. ; her  true  name  is  ‘ Bisbina  Napoleone.’  When 
she  had  become  conscious  of  her  true  origin,  the  whole  of  her  past  was 
illuminated  with  a new  light. 

The  Princes  and  Marquises  who  had  paid  attention  to  her  at  the  hydro- 
pathic establishment  were  all  of  the  Bonaparte  family — all  relations  of 
hers  who  had  come  incognito  to  see  her,  to  learn  what  she  was  like,  and 
to  protect  her.  The  sums  of  money  that  these  persons  paid  to  her  father 
for  the  bath-treatment  were  really  subsidies  from  her  royal  relatives  to 
maintain  her  in  a style  worthy  of  her  position  ; in  fact,  those  payments 
were  a part,  although  a very  small  part,  of  her  royal  inheritance.  Now 
she  wishes  to  leave  the  asylum,  where  she  cannot  live  with  all  the  ease 
and  style  due  to  her  position  ; but  she  will  not  return  to  her  lover,  who, 
however,  is  the  only  person  who  really  takes  any  interest  in  her,  and 
comes  to  see  her  frequently.  If  she  left  the  asylum,  she  would  never  wish 
to  hear  of  him  again.  She  and  her  daughter  would  go  and  live  with  her 
royal  parents,  who  would  not  tolerate  the  presence  of  her  lover  in  their 
household. 

In  the  asylum  her  behaviour  is  correct,  but  proud  and  haughty.  She 
walks  about  alone,  and  does  not  talk  either  with  the  nurses  or  with  the 
other  inmates.  It  seems  that  she  has  the  utmost  contempt  for  all  of 
them.  With  the  doctors  she  is  a little  complaisant,  but  only  because  she 
understands  that  the  possibility  of  her  liberation  depends  upon  them. 
She  does  not  believe  that  she  has  enemies  outside  of  the  asylum,  and,  in 
fact,  she  has  not  any  real  delirium  of  persecution.  Once  she  thought  that 
she  was  being  persecuted  by  her  rivals  in  love,  and  now  she  supposes  that 
the  family  Long,  might  have  some  interest  in  keeping  her  in  the  asylum,  so 


PARANOIA 


583 


that  they  might  get  possession  of  her  wealth.  On  this  point,  however,  she 
does  not  insist.  The  only  florid  and  systematized  delirium  is  that  of 
grandeur,  and  we  have  seen  the  genesis  and  the  development  of  it. 

The  following  case  is  an  example  of  paranoia,  perhaps  develop- 
mental, which  in  its  early  evolution  assumed  the  form  of  delirium  of 
grandeur,  strengthened  by  fugitive  hallucinations,  but  was  rapidly 
transformed  into  a pronounced  delirium  of  persecution  that  under- 
went no  further  modification  : 

j 

Observation  XVI. — Di  N.  F.,  thirty-nine  years  old,  bachelor, 
scrivener,  w^s  admitted  to  the  asylum  on  August  16,  1890. 

Family  History. — His  father  suffered  from  gout.  A maternal  uncle, 
a priest,  is  so  much  feared  in  his  district  that  the  people  called  him  ‘ The 
Fierce.’ 

The  patient  entered  upon  an  ecclesiastical  career,  and  took  the  minor 
Orders ; but  he  gave  up  his  intention  of  becoming  a priest  on  hearing  it 
said  in  public  that  his  uncle,  who  was  a priest,  had  been  a scoundrel  and 
a thief.  Later  on  he  entered  the  army  as  a volunteer. 

He  has  been  a confirmed  masturbator,  even  in  adult  life. 

He  is  of  more  than  ordinary  intelligence,  credulous,  and  subject  to 
suggestion.  There  is  great  predominance  of  sexual  ideas  in  his  mind, 
and  since  he  was  a youth  he  has  had  a great  desire  to  marry. 

When  he  was  in  the  army  he  began  to  suffer  from  very  vague  and 
transitory  sensory  disturbances,  which  opened  the  way  for  ideas  of 
delirium. 

His  mind  became  saturated  with  the  desire  to  marry  and  with  erotic 
ideas,  while  his  health  was  undermined  by  onanism  ; and  one  evening  he 
had  hallucinations,  probably  oneiric,  of  which  he  gives  the  following 
account  : 

‘ I had  been  told  off  for  duty  in  the  fortress  of  St.  Elmo,  and  one 
evening  about  ii  p.m.  one  of  my  corporals  in  the  fourth  company  came 
to  within  a short  distance  of  me,  and  called  out  the  following  words  in  my 
direction  : “ Marriage  with  a royal  Princess  ” ; and  at  the  same  time  he 
held  out  before  me  a picture,  in  the  centre  of  which  was  the  Pope,  sur- 
rounded by  all  the  crowned  heads  of  Europe.  After  the  advice  thus  given 
me,  and  when  I had  clearly  seen  and  learned  the  subject  of  the  picture, 
I gave  no  answer  to  the  words  addressed  to  me,  but  resumed  my  own 
work. 

‘ The  significance  of  these  words  began  to  develop  secretly  in  my  mind, 
both  day  and  night,  and  my  mind  was  firmly  made  up  to  endeavour  to 
arrange  this  marriage,  and  to  hasten  it  on  as  rapidly  as  possible. 

‘ In  view  of  the  great  importance  of  the  matrimonial  alliance  thus 
suggested  to  me — for  I was  not  of  the  rank  or  in  the  position  to  marry  the 
person  indicated,  namely,  a daughter  of  a reigning  Prince — I had  arranged 
and  determined  in  my  own  interest  to  adhere  firmly  to  my  resolution 
“ never  to  contract  matrimony  unless  the  young  lady  concerned  was 
handsome,  cheerful,  well  brought  up,  a lady,  of  good  character,  with  a 
considerable  dowry,  and  well  connected.” 

‘ I swear  and  confess  that  my  mind  was  very  much  inclined  to  this  pro- 
posal, and  I endeavoured  to  use  every  possible  means  to  effect  the  pro- 
jected and  much-desired  marriage  advised  me  by  the  corporal  I have 
already  mentioned,  because,  in  the  first  place,  it  was  advantageous,  and, 
in  the  second  place,  it  would  insure  me  a sound  financial  position,  while, 
lastly,  it  would  enable  me  to  satisfy  my  instinct  normally. 

‘ But  the  King  became  acquainted  with  this  very  proper  idea  of 


584 


PSYCHIATRY 


mine,  and  with  the  plans  that  I had  already  set  on  foot  to  realize  this 
ambition  of  my  earliest  youth,  which  the  corporal’s  words  had  but  served 
to  rouse  to  stronger  life.  To  prevent  me  attaining  my  object,  then,  he 
soon  afterwards  sent  a confidential  messenger  specially  to  me.  I was 
then  attached  to  the  Registration  Office  in  the  capacity  of  a scrivener, 
under  the  orders  of  the  Colonel,  and  one  day,  while  I was  looking  out  of  the 
window,  a person  whom  I did  not  see,  but  whose  words  I heard  clearly  and 
distinctly,  as  he  was  standing  at  a point  a very  little  way  from  the  office, 
called  out  in  a loud  voice  something  to  the  following  effect : “ Write  a 

letter  to  the  King,  and  call  him ” (here  follow  some  insulting  and 

trivial  expressions).’ 

The  first  idea,  suggested  by  a hallucination,  was  followed  by  the 
logical  complementary  conception  of  the  resentment  of  the  King  and  by 
the  fear  of  punishment,  so  that  in  this  state  of  mind  the  patient  had 
hallucinations  that  might  be  termed  hallucinations  of  contrast  or  of 
reaction  against  the  King,  whose  indignation  he  had  already  begun  to 
fear.  Whilst  in  this  state  of  mind,  and  when  all  his  companions  were 
sleeping,  and  everything  was  wrapped  in  the  most  profound  stillness, 
he  heard  voices  coming  from  a small  passage  beside  the  dormitory,  saying 
to  him,  ‘ Cut  your  throat,  cut  your  throat,  cut  your  throat !’  and  they 
repeated  the  words  so  persistently  that  he  seized  his  bayonet  and  stabbed 
himself  several  times  in  the  throat,  although  he  had  no  intention  of  suicide. 
Still  the  voices  did  not  desist,  but  added,  ‘ Thrust  it  in,  thrust  it  in,  thrust 
it  in  !’  for  none  of  the  thrusts  already  made  had  proved  fatal.  There  was 
profuse  haemorrhage,  and  in  the  morning  the  doctors  found  him  to  be  in  a 
very  serious  condition  owing  to  the  great  quantity  of  blood  he  had  lost. 
Whose  were  those  voices  ? He  saw  no  one,  and  certainly  they  were  not 
the  voices  of  his  companions  in  the  dormitory.  This  puzzling  question, 
as  well  as  the  incident  itself,  caused  him  much  mental  worry.  Thinking 
oyer  the  matter  and  collecting  a number  of  clues,  he  came  to  the  conclu- 
sion, many  years  afterwards,  that  the  voices  belonged  to  carabineers  and 
police,  sent  expressly  by  the  King,  who  had  agreed  with  his  parents  to 
destroy  him.  From  that  time  forward  he  was  on  his  guard  against  all 
possible  enemies. 

About  a year  elapsed,  when  one  night,  as  he  lay  asleep  in  his  room, 
he  was  disturbed  by  the  sound  of  keys  near  to  his  door.  The  idea  flashed 
through  his  mind  that  assassins  had  perhaps  come  to  murder  him.  He 
did  not  lose  his  presence  of  mind,  but  caught  up  his  rifle  and  fired  into  the 
air.  Then,  after  he  had  dressed  himself,  he  opened  the  door  and  went 
down  the  stair ; but  his  enemies  had  already  fled,  and  there  was  nobody  to 
be  found. 

Through  an  extensive  series  of  facts  and  circumstances,  too  long  to 
relate  here,  the  patient  came  to  have  a very  firm  notion  that  his  parents 
were  trying  to  secure  his  death,  in  order  to  obtain  possession  of  his 
property. 

To  achieve  their  purpose,  not  only  did  they  enter  into  an  agreement 
with  the  Government,  which  had  persecuted  him  ever  since  he  had  been  in 
the  army,  but  they  put  poison  in  his  food,  and  employed  ever  so  many 
other  means,  with  the  express  idea  of  preventing  his  marriage.  He 
was  much  given  to  onanism,  and  this,  he  said,  had  produced  paralysis, 
of  which  he  would  certainly  have  died  had  he  not  noticed  it  in  time.  By 
marrying,  he  argued,  he  would  have  got  rid  of  that  pernicious  habit,  and 
the  paralysis  would  certainly  not  have  occurred. 

This  honest  intention  of  his  was  opposed,  not  only  by  the  Government 
but  also  by  the  doctors,  and  by  all  his  relatives,  with  whom  his  enemies 
leagued  themselves  in  their  conspiracies  against  him ; and,  in  fact, 
although  he  had  been  frequently  visited  by  various  physicians  in  the 
country,  not  one  of  them  had  opened  his  mind  to  him  or  made  him 


PARANOIA 


585 


understand  what  was  the  origin  of  his  troubles.  It  was  only  when  he 
came  into  the  asylum  that  he  felt  any  improvement.  One  of  the 
physicians  suddenly  found  out  the  cause  of  his  malady,  and  told  him  of  it. 
He  at  once  gave  up  the  bad  habit  of  masturbation,  and  he  found  that 
ever  so  many  phenomena  that  had  formerly  caused  him  serious  apprehen- 
sion disappeared — for  example,  debility,  headache,  and  ulceration  of  the 
mouth.  This  delirium  remained  for  many  years,  systematized  and  un- 
changed. 

In  the  asylum  he  behaved  like  a sane  person,  being  orderly  and  correct 
in  his  conduct.  Everything  he  said  was  quite  to  the  point.  He  assisted 
the  attendants,  was  industrious  and  composed.  Still,  he  had  a profound 
and  rooted  conviction  that  there  was  a conspiracy  between  his  family  and 
the  Government  to  do  him  harm,  to  prevent  him  marrying,  and  to  cause 
his  death. 

This  case  is  very  interesting,  for  it  proves  that  the  psychopathic 
predisposition  reveals  itself  in  extreme  onanism,  which  in  its  turn 
produces  debility,  headache,  kinesthetic  paresthesia,  and  also 
defects  of  judgment.  The  altered  kinesthesis  and  the  desire  to 
marry  prepared  the  way  for  the  hallucinations.  These  first  of  all 
gave  rise  to  the  dream  of  a great  marriage  ; then,  by  contrast,  they 
caused  actions  of  a very  dangerous  nature,  such  as  making  use  of 
the  weapons  that  he  had,  in  obedience  to  hallucinatory  injunctions. 
The  hallucinations  were  not  repeated,  but  they  brought  before  his 
mind  the  question  of  the  origin  of  the  phenomenon,  and  after  long 
reasoning  he  arrived  at  a paranoic  conclusion,  which  was  straight- 
way accepted  without  further  discussion. 

The  frequency  of  the  primary  character  of  the  delirium  of 
grandeur  cannot  be  doubted.  It  may  or  may  not  be  followed, 
sooner  or  later,  by  the  delirium  of  persecution.  Sometimes,  as  in 
Observation  XV.,  the  delirium  of  persecution  is  grafted  on  to  the 
ambitious  delirium  before  the  latter  is  completely  developed.  In 
this  case  the  delirium  of  persecution  is  rapid  in  efflorescence,  so  that 
it  seems  primary,  although  not  really  so,  and  after  a time  disappears 
altogether,  with  the  development  of  the  delirium  of  grandeur.  The 
two  fundamental  characters  of  the  personality,  suspicion  or  fear, 
and  ambition  or  vanity,  frequently  coexist.  It  depends  on  the 
predominance  of  one  or  the  other,  or  perhaps  on  external  circum- 
stances, as  we  have  already  seen,  whether  delirium  of  grandeur  or 
delirium  of  persecution  be  first  developed. 

Delirium  of  Persecution. — This  may  occur  alone,  or  it  may 
develop  in  a progressive  fashion  with  complementary  delirium  of 
grandeur  at  an  earlier  or  later  period.  Predisposed  individuals 
show  an  anomaly  of  character  from  adolescence.  They  are  timid, 
preoccupied  with  every  trifle,  and  especially  so  with  their  health. 
They  are  inclined  to  lead  a solitary  life,  are  reserved,  and  often  very 
emotional,  addicted  to  onanism,  or  very  studious.  These  last  find 
no  attraction  in  their  companions,  and  do  not  join  in  their  games. 
They  go  straight  from  home  to  school,  and  back  again.  They  wish 


586 


PSYCHIATRY 


to  take  the  first  place  in  school  (ambition),  and  sometimes  they  i 
succeed,  but  in  other  cases — the  weaker  among  them — they  fail. 
Protracted  and  uninterrupted  brain  work  (mental  effort),  and  some- 
times onanism,  give  rise  to  a certain  feeling  of  discomfort.  They 
have  vague  pains  in  the  head,  gastric  disorders,  and  changes  of 
humour.  These  disturbances  are  often  primary,  and  do  not  require  : 
mental  effort  to  excite  them  ; but  they  preoccupy  the  patients,  and  ' 
render  them  more  subjective  than  they  were  originally.  Thus  ■ 
begins  the  habit  of  self-observation,  along  with  a tendency  towards  I 
interpretation  of  the  new  phenomena.  This  condition  of  affairs  [ 
may  last  a very  long  time,  and  sometimes  the  malady  is  not  further 
developed. 

In  most  cases  the  paraesthesia  and  the  altered  kincesthetic  sense, 
of  which  the  sufferer  is  perfectly  conscious,  are  accompanied  by 
strange  ideas.  A patient  will  say  : ‘So  many  ideas  come  into  my 
mind  that  I never  thought  of  before.’  He  is  not  in  a position  to 
regulate  these  ideas,  and  among  them  there  may  be  one  that  is 
predominant,  and  gives  a certain  direction  to  the  nascent  delirium. 
He  can  no  longer  follow  at  will  the  logical  course  of  reasoning  ; the 
ideas  belonging  to  ‘ the  unconscious  ’ are  breaking  out  of  restraint. 
The  patient  becomes  more  gloomy,  isolates  himself  still  more,  and  ’ 
becomes  more  irritable. 

His  attention  is  especially  directed  to  finding  the  explanation 
of  this  change,  which  reflects  itself  on  his  surroundings.  Those  ' 
with  whom  he  comes  in  contact  speak  another  language  than  ■ 
before,  the  physiognomies  of  those  around  him  appear  to  be  changed,  ' 
and  it  seems  all  regard  him  with  no  friendly  air. 

Meanwhile  sleep  is  interrupted,  and  has  no  restoring  power.  It 
is  broken  by  dreams  that  are  repulsive  and  horrible.  This  frightens  , 
the  patient  still  more,  irritates  him,  and  causes  a certain  confusion.  • 
It  is  usually  at  this  point  that  sensory  disorders,  illusions,  and  1 
hallucinations  commence.  On  the  street  he  finds  that  people  look  \ 
at  him  with  an  air  of  contempt,  smile  scornfully  at  him,  make  1 
faces  at  him,  and  ‘ signs  ’ referring  to  him.  Sometimes  even  the  \ 
persons  of  his  own  family  are  laying  traps  for  him,  although  the 
mother  is  almost  always  excluded  from  this  delusion. 

In  the  newspapers,  patients  of  this  class  find  articles  or  phrases 
that  they  suspect  to  contain  allusion  to  themselves.  The  con- 
versation of  people  who  pass  along  the  streets  at  night  they  believe 
to  be  about  themselves,  and  they  think  that  those  persons  are  con- 
spiring against  them.  At  this  point  the  paranoic  subject  is  already 
caught  inextricably  in  the  net  of  the  delirium  of  persecution,  or 
delirium  of  relations,  according  to  Wernicke. 

The  sufferer  becomes  more  attentive,  and  examines  these  new 
facts,  anxious  to  learn  at  all  costs  what  it  is  all  about,  who  it  is  that 
is  busying  himself  with  him,  and  why  such  and  such  a conspiracy 
— for  there  certainly  is  one — is  being  directed  against  him. 


PARANOIA 


587 


The  reply  is  given  either  by  delirious  explanatory  representa- 
tions or  by  hallucinations,  which  furnish  new  subject-matter 
relating  to  the  disease.  At  first  the  hallucinations  are  elementary 
in  character— some  hiss  or  whistle,  some  indefinite  sounds  or  vague 
words,  the  signification  of  which  is  not  yet  properly  understood, 
but  which  the  subject  in  most  cases  interprets  as  an  insult,  or  he 
may  believe  that  people  ‘ wish  to  confuse  ’ him. 

Sometimes  there  are  psycho-motor  verbal  hallucinations,  while 
in  other  instances  the  hallucinations  are  the  reflex  of  the  patients’ 
own  thoughts  {vide  Part  II.,  chapter  on  Hallucinations). 

With  these  hallucinations  others  are  frequently  associated,  con- 
nected with  the  senses  of  smell  and  taste.  The  patient  then 
declares  that  people  are  scattering  poisonous  gases  all  about ; he 
smells  them  ; he  is  breathing  foetid  air.  They  are  putting  poison  in 
his  food  ; the  food  has  no  longer  the  same  taste  as  before.  They  have 
poisoned  the  water.  [One  of  the  patients  who  came  under  my  obser- 
vation had  taken  water  to  an  analyst  to  have  it  analyzed,  and  had 
carried  another  sample  to  the  Public  Prosecutor.]  The  patient  no 
longer  feels  safe.  He  becomes  agitated  ; very  often  he  is  threatening. 

From  this  point  the  malady  pursues  one  of  two  directions.  If 
the  sufferer  was  a timid  character,  he  feels  himself  discouraged  and 
debased.  He  cannot  bear  the  endless  traps  that  are  being  laid  for 
him,  the  torture  that  they  cause  him,  or  the  insults  to  which  he  is 
continually  being  subjected.  He  already  indulges  the  idea  of 
suicide,  and  later  on  he  may  put  it  into  practice.  In  most  instances 
he  seeks  to  escape  this  fatality  by  taking  refuge  behind  some  trusted 
member  of  the  family,  should  there  remain  anyone  towards  whom 
his  affection  has  not  been  altered  by  the  trouble  that  has  come 
upon  him.  These  cases  are  the  resigned  paranoiacs. 

In  another  group  of  cases  reaction  succeeds  the  more  or  less 
temporary  discouragement.  The  persecuted  subject  accepts  the 
struggle,  decides  to  make  a way  for  himself,  and  in  a spirit  of  ven- 
geance he  sets  out  to  seek  his  persecutors  (presumed  enemies).  He 
goes  over  the  story  of  his  past  life,  with  the  result  that  events 
which  were  of  very  slight  importance  now  acquire  great  value  as 
clues  to  the  personality  of  his  supposed  persecutors.  The  cases 
noted  hereafter  prove  that  very  often  the  paranoic  subject  seeks  in 
vain  to  establish  the  identity  of  his  enemies  ; in  fact,  this  is 
generally  the  rule. 

They  insult  him,  he  says,  they  make  him  miserable,  they  elec- 
trify him,  they  act  upon  him  by  suggestion,  they  wish  to  put  him 
to  death  ; but  he  does  not  know  why  that  is  so,  or  who  are  his 
persecutors.  The  futility  of  the  search  and  the  necessity,  not  only 
of  identifying  his  enemies,  but  of  learning  the  details  of  the  plot,  of 
which  thenceforth  he  has  no  longer  any  doubt,  ultimately  force  him 
to  the  conviction  that  secret  societies — the  Jesuits,  the  Freemasons, 
the  Maffia — the  Government,  or  a chief  of  a Government  Depart- 


588 


PSYCHIATRY 


ment,  desire  to  get  rid  of  him.  The  hallucinations  continually 
add  fresh  fuel  to  the  fire.  His  enemies  come  to  insult  him  even  in  ! 
his  own  room  ; they  are  concealed  behind  the  door,  behind  the 
walls,  above  the  ceiling,  and  under  the  floor.  ^ I hear  the  voices 
everywhere,’  he  says,  ‘ and  they  have  found  a way  of  getting  at 
me,  even  in  my  own  room  when  I take  refuge  there.’  Pareesthesia  I 
of  the  face  is  interpreted  as  wind  blown  by  his  enemies  or  as  ! 
electricity.  j 

The  sufferer  has  no  rest.  If  he  is  armed  he  becomes  threatening,  j 
and  discharges  his  weapon  in  the  direction  of  the  voices.  He  runs 
off  to  the  police  or  the  Public  Prosecutor.  He  may  change  his 
residence,  and  go  to  a foreign  country  to  escape  the  torment,  but 
the  persecution  follows  him  everywhere.  A patient  of  mine 
travelled  all  over  Italy,  continually  persecuted  by  threatening 
voices  and  by  the  figure  of  a woman  who  wished  to  take  revenge 
on  him.  Then  he  left  for  America,  but  at  New  York,  at  Chicago 
and  Philadelphia,  the  same  voices  and  the  same  woman’s  figure 
haunted  him.  He  returned  to  Italy,  and  eventually  becoming  the 
victim  of  extreme  agitation,  was  brought  to  the  asylum  (migratory 
pananoiacs,  Foville). 

If,  on  the  other  hand,  the  paranoiac  Axes  the  identity  of  his  per-  ' 
secutors,  he  tries  all  legal  means  to  free  himself  from  the  latter.  ■ 
Failing  in  that,  he  takes  the  law  into  his  own  hands,  and  accom-  ' 
plishes  his  vendetta  either  impulsively,  on  the  slightest  occasion,  ' 
or  with  premeditation,  in  which  case  he  is  cruel  and  remorseless!  ’ 
He  will  cut  a throat  with  a knife,  use  firearms  at  a very  short  range,  ! 
set  fire  to  buildings,  etc. 

From  time  to  time,  when  the  hallucinations  are  more  vivid,  he 
becomes  impulsive,  violent,  sudden  in  his  movements,  and  attacks  : 
the  first  person  he  meets.  He  displays  extraordinary  strength  and  ' 
ferocity,  in  this  respect  resembling  the  epileptic.  The  persecuted  j 
becomes  persecutor  (Lasegue),  and  is  certainly  one  of  the  most  ! 
dangerous  of  patients. 

In  the  asylum,  as  in  the  family,  paranoiacs  of  this  class  are  ? 
always  mistrustful,  threatening,  and  hard.  They  have  no  affec- 
tion for  anyone  ; they  hate.  They  do  not  reveal  their  anxieties  1 
frankly  and  openly.  They  suspect  everyone,  no  matter  what  | 
degree  of  kindness  is  used  towards  them,  and  they  are  among  the  ! 
most  dangerous  of  patients.  | 

As  a rule,  such  an  intense  degree  of  delirium,  with  extremely 
vivid  hallucinations  and  impulsive  reaction,  does  not  last  any  | 
length  of  time.  This  condition  is  most  frequent  towards  the  end 
of  the  prodromal  period,  and  in  the  period  of  efflorescence  of  the  ji 
delirium,  especially  at  the  beginning.  Later  on,  once  the  delirium  ii 
has  been  clearly  formulated,  and  there  is  a fixed  consciousness  of  j: 
the  change  that  has  taken  place  in  the  surroundings,  there  comes  'i 
a slow  adaptation  to  the  new  conditions  of  existence,  followed  by  ^ 


PARANOIA  589 

comparative  calm,  interrupted  now  and  then  by  phases  of  agita- 
tion and  impulsiveness. 

The  delirium  is  thenceforward  systematized,  crystallized,  and 
reinforced  from  time  to  time  by  hallucinations.  It  may  be  limited 
in  extent,  and  the  patient  may  take  up  some  occupation,  making 
a certain  use  of  his  culture  and  his  habitudes,  or  the  whole  mental 
patrimony  may  be  assimilated  by  the  delirium,  whilst  power  of 
critical  judgment  is  almost  completely  suppressed.  The  logical 
power  also  decays  slowly,  and  the  syntactical  form  of  speech  and 
writing  is  altered.  The  conversation  is  strange,  and  the  round- 
about ways  in  which  conclusions  are  reached  are  very  striking 
(paralogia). 

Neither  the  ordinary  form  of  language  nor  the  common  vocabu- 
lary is  sufficient  for  the  new  personality  in  its  new  relations  with 
the  external  world.  New  words  are  required  for  the  new  mental 
syntheses,  answering  to  the  persecution,  the  persecutors,  and  the 
changed  personality,  and  so  the  subjects  create  new  vocables  that 
serve  the  purpose  better.  These  are  the  neologisms  so  thoroughly 
studied  by  Tanzi.  With  the  paralogia  there  gradually  commences 
a process  of  mental  decay  that  is  sometimes  rapid,  but  sometimes 
is  established  only  after  ten  to  fifteen  years,  or  even  longer. 

Some  of  these  paianoiacs,  persecutors  rather  than  timid  subjects, 
manifest  ideas  of  grandeur  at  an  earlier  or  later  period  in  the  disease. 

These  ideas  pre-exist  in  the  vain  and  haughty  temperament  of 
the  persecuted  subject.  They  gain  the  upper  hand  from  time  to 
time  during  the  period  of  effiorescence  of  the  delirium  of  persecu- 
tion, or  even  in  the  prodromal  period.  They  are  organized  and 
synthetized  most  frequently  in  the  period  of  paralogia,  if  I must 
use  the  expression,  just  when  mental  decay  is  commencing.  When 
these  ideas  are  thus  organized,  and  the  personality  has  been  trans- 
formed by  the  new  products,  the  two  deliria  coexist,  with  preva- 
lence of  the  delirium  of  grandeur,  which  gives  the  intonation  to  all 
movements  and  to  all  the  attitudes  of  the  paranoic  subject. 

This  transformation  hardly  ever  occurs  in  those  persecuted 
subjects  who  have  no  hallucinations.  These  latter  are  rare. 

The  paranoic  delirium  of  jealousy  is  merely  one  mode  of  manifes- 
tation of  the  suspicious  paranoic  temperament.  In  this  form  of 
paranoia  the  subject  is  eminently  suspicious,  generally  poor  in 
mental  resource,  proud,  and  believes  himself  to  be  offended  in 
some  point,  very  uncertain,  but  still  embodying  what  the  common 
man  holds  most  dear — love,  pleasure,  or  honour.  This  possession 
is  an  intrinsic  part  of  the  proper  personality,  but  is  entrusted  to 
another  being,  with  which  the  personality  has  common  interests  of 
an  extremely  intimate  character,  and  this  other  has  a will  of  its 
own.  This  is  not  at  all  a special  form  of  paranoia. 

The  jealous  paranoic  subject,  like  the  persecuted  subject,  is 
timid  and  jealous,  or  proud  and  jealous,  with  no  idea  of  the  limits 


590 


PSYCHIATRY 


of  the  right  of  possession.  This  form  of  paranoia,  in  its  various 
degrees  of  manifestation,  follows  out  the  same  phases  as  the  delirium 
of  persecution.  It  gives  rise  to  mutilations  in  the  case  of  women, 
or  to  murder,  more  frequently  resorted  to  by  men.  I have  made 
reference  to  one  case,  and  Maschka,  Pellegrini,  and  others  have 
published  cases. 

The  following  observations  are  examples  of  simple  paranoia 
with  hallucinations  : 


Observation  XVII. — C.  Ros.,  of  Messina,  forty-live  years  of  age, 
bachelor,  coming  from  America,  was  received  into  the  asylum  on 
November  28,  1895.  His  parents  had  died  of  cholera  many  years  before. 
We  have  never  succeeded  in  finding  out  whether  there  had  been  any 
cases  of  neuropathy  or  psychopathy  in  the  family. 

From  his  infancy  up  till  about  fifteen  he  was  a sacristan.  When  his 
parents  died,  as  he  could  not  live  on  the  money  he  got  for  his  church 
services,  and,  further,  as  he  was  utterly  tired  of  that  life,  he  chose  to  serve 
as  a waiter  in  a cafe  of  low  order.  After  a year  or  two  he  abandoned  that 
profession  also,  and  went  to  work  with  a cloth  manufacturer,  with  whom 
he  remained  for  six  years,  when  he  was  attacked  by  granular  conjunc- 
tivitis, and  had  to  resign  his  situation.  As  he  was  of  rather  a touchy 
disposition,  he  immediately  gave  instructions  that  the  money  still  owing 
him  should  be  paid  back  to  the  employer,  and  he  was  the  more  anxious 
about  this  because  a day  or  two  before,  for  some  trifling  reason,  he  had 
broken  off  all  relations  with  his  fiancee,  a relative  of  his  employer.  He 
was  at  once  reduced  to  want  at  the  very  time  when  he  had  to  consult  a 
medical  man. 

After  his  recovery  he  took  to  the  sea,  and  sailed  for  many  years  as  a 
foreign-going  seaman  on  vessels  of  Italian  and  other  nationalities.  In 
1891,  however,  he  was  forced  to  abandon  this  new  vocation  owing 
to  the  development  of  a right  inguinal  hernia  following  upon  some 
unusual  strain.  He  therefore  determined  to  remain  in  America,  where 
he  made  a living  by  vending  fruit. 

He  has  had  no  previous  illnesses  of  any  consequence. 

Even  as  a boy  he  was  not  fond  of  the  thoughtless  life  of  the  young. 
He  has  always  been  sparing  in  his  indulgence  in  venereal  pleasures, 
particularly  in  the  last  few  years  ; but,  on  the  other  hand,  it  seems  that 
he  has  not  been  altogether  free  from  the  vice  of  masturbation.  He  has 
suffered  from  gonorrhoea  more  than  once,  and  he  contracted  an  ulcer 
which  we  cannot  be  sure  was  not  syphilitic.  He  has  been  an  inveterate 
smoker  and  chewer  of  tobacco.  He  was  not  habitually  a heavy  drinker, 
but  whenever  temptation  was  placed  in  his  way,  he  could  not  refrain 
from  indulging. 

In  America  he  lived  as  a true  misanthrope  (paranoic  character).  Not 
only  did  he  not  care  to  make  acquaintance  with  the  numerous  Italians - 
living  there,  but  he  even  avoided  those  who  came  from  his  native  island. 
He  lived  with  an  English  family,  but  he  had  as  little  to  do  with  them  as 
possible.  His  life  was  hard  enough,  for  all  his  energies  were  devoted  to 
increasing  his  savings.  He  did  his  own  cooking,  and  he  never  allowed 
himself  any  sort  of  recreation. 

His  vocation  caused  him  to  pass  a great  deal  of  his  time  on  the  streets, 
and  numbers  of  children  went  to  him  to  buy  fruit.  He  gradually  lost  his 
innate  roughness,  and  used  to  amuse  himself  by  joking  with  them. 
After  repeated  inquiries,  we  have  managed  to  find  out  with  certainty  that 
one  day  there  came  into  his  mind  a suspicion  that  in  New  York  people 
believed  that  he  had  carnal  relations  with  those  children  (psychic 


X 


i 

I 

j 


PARANOIA 


591 


contrast).  That  belief  began  to  take  such  a hold  of  his  mind  that  it^ 
became  painful  for  him  to  live  tormented  by  such  a cruel  suspicion,  and 
he  went  to  a druggist  whose  shop  was  opposite  his  stance  to  ask  him 
whether  he  knew  anything  of  those  rumours  that  were  current.  Not- 
withstanding the  assurances  and  the  encouragement  given  him  by  the 
druggist,  he  could  not  rest.  A dream  gave  further  impulse  to  the  growth 
of  the  germinating  delirium,  and  the  more  so  because  it  had  been  his 
experience  that  after  a dream  of  a certain  sort  a misfortune  was  sure  to 
occur  to  him.  Thereafter  followed  sensory  disturbances,  illusions,  and 
hallucinations.  He  commenced  to  see  waggons,  generally  empty,  some- 
times laden  with  useless  rubbish  or  sand,  that  always  tried  to  run  him 
down  at  a gallop  the  moment  he  noticed  them.  At  other  times,  passers-by 
no  sooner  came  up  to  him  than  they  threw  a stone  at  him,  or  gave  him 
a blow  with  a stick,  or  called  out  loudly  to  him  : ‘ You  ought  to  be  arrested ; 
you  should  be  put  to  death  !’  He  had  no  peace,  and,  as  he  believed  that 
the  whole  city  was  up  against  him,  he  thought  it  best  to  return  to  Italy. 

During  the  voyage  he  had  not  a moment’s  quiet,  and  the  sensory 
disturbances  became  more  and  more  intense.  He  thought  that  a party 
favourable  to  him  had  been  formed,  and  that  it  defended  and  applauded 
him,  while  an  opposing  party  endeavoured  to  destroy  him  at  all  costs. 

He  broke  out  into  violent  conduct,  shouted,  and  made  such  a noise  that 
he  had  to  be  locked  up.  As  soon  as  he  arrived  in  Naples,  he  was  taken 
to  the  asylum. 

There  the  patient  is  generally  dull,  self-engrossed,  and  gloomy.  He 
takes  no  interest  in  anything,  and  looks  at  no  one.  He  walks  up  and  down 
the  hall  with  his  head  forward  and  his  arms  folded,  with  the  aspect  of  one 
who  is  brooding  over  some  very  serious  matter  that  has  to  be  decided. 

A smile  often  flits  across  his  face,  but  it  is  a strange  and  forced  smile  that 
clearly  reveals  the  internal  struggle  in  his  mind.  To  him  may  well  be 
applied  that  phrase  of  one  of  the  Italian  poets,  ‘ Questo  che  par  sorriso. 
ed  e dolore.’  If  he  is  addressed  and  spoken  to  frankly,  in  a friendly  and 
encouraging  tone,  he  stands  and  looks  at  the  speaker  for  a certain  time 
in  silence  and  with  an  air  of  suspicion  ; then  he  gives  his  answer,  which  is 
always  short  and  generally  faulty  and  incomplete.  Not  always,  however, 
is  he  to  be  found  in  this  state  of  exterior  and  apparent  calm.  There  are 
rare  periods  in  which  he  is  subject  to  great  agitation.  This  happens 
particularly  when  he  is  a prey  to  sensory  disturbances,  for  terrifying 
hallucinations  dismay  and  prostrate  him.  He  hears  threatening  voiced 
telling  him  that  in  a short  time  he  will  be  put  to  death,  he  will  be  cut 
to  pieces,  stoned,  and  so  forth.  He  hears  the  steps  of  persons  coming 
to  him  to  carry  out  their  murderous  intentions.  At  such  moments  it  is 
very  difficult  to  keep  the  patient  under  control,  for  he  breaks  out  into 
mania,  runs  towards  the  doors  and  tries  to  force  them,  yells  and  shouts 
at  the  pitch  of  his  voice,  and  when  he  sees  that  all  is  useless  he  com- 
mences to  threaten  and  imprecate.  If  he  hears  a noise,  he  thinks  that 
his  executioners  are  approaching.  If  he  sees  a chair,  he  declares  that  it 
is  in  that  chair  he  will  sit  to  be  fusilladed.  The  friendly  and  reassuring 
face  of  the  doctor  wears  for  him  a look  of  pity  ; he  is  always  looking 
around  him  and  finding  hostility  on  every  side. 

The  sensory  disturbances  are  not  always  so  intense  ; as  a rule,  indeed, 
they  are  fleeting — for  the  most  part  illusions — and  do  not  provoke  such 
violent  reactions.  At  other  times  the  patient  assumes  a threatening 
attitude  towards  those  in  charge  of  him  : they  wish  to  put  him  to  death, 
but  he  does  not  intend  to  let  them  have  their  will,  and  if  anyone  has  any 
evil  intentions  against  him,  let  him  think  twice  before  trying  to  put  them 
into  effect.  He  will  face  his  enemies,  who  will  have  to  make  their  account 
with  him,  and  woe  to  them  ! 

His  ideation  revolves  especially  about  those  facts  that  form  the^ 


592 


PSYCHIATRY 


I 


nucleus  of  his  ideas  of  delirium.  He  cannot  think  of  anything  without 
' giving  it  a signification  hostile  to  himself.  He  feels  that  he  has  been 
debased,  and  that  he  is  the  object  of  the  ill-will  of  others,  but  he  cannot 
say  what  is  the  reason  of  his  torments.  ‘ I do  not  know,’  is  his  constant 
reply.  ‘ There  are  intrigues  against  me — I have  continual  proofs  of  that — 
but  I cannot  tell  who  is  at  the  bottom  of  them.  Everybody  is  in  a con- 
's^ spiracy  against  me,  and  continual  demonstration  is  made  before  me.’ 

There  is  a certain  slowness  in  the  development  of  his  ideas.  As  he  is 
preoccupied  with  other  thoughts,  his  replies  are  slow  and  often  not  to 
the  point. 

He  is  very  suspicious,  and  often  he  is  unwilling  to  reveal  any  of  his 
thoughts,  going  the  length  of  denying  what  he  has  previously  stated. 

The  perceptive  process  (except  the  sensory  disturbances  of  which  we 
have  already  spoken)  and  the  memory  are  generally  normal,  if  we  bear 
in  mind  what  is  to  be  expected  from  an  individual  of  his  class,  of  not  very 
high  mental  development. 

Spontaneous  attention  is  very  lively  during  the  periods  of  excitement, 
when  all  external  stimuli  reach  the  threshold  of  consciousness  and  are 
interpreted  in  a hostile  sense,  as  already  remarked,  whilst  it  appears  to 
be  weak  during  the  periods  of  calm  ; but,  as  the  patient  is  intent  on 
ruminating  and  thinking  over  his  delirious  ideas,  he  presents  the  type 
of  the  absorbed  attentive  subject.  In  such  cases  it  is  difficult  to  arouse 
the  attention,  which  requires  to  be  continually  maintained  ; otherwise 
he  will  suddenly  fall  back  into  his  usual  silence  and  resume  his  ordinary 
suspicious  and  pensive  physiognomy. 

He  lives  apart  from,  and  indifferent  to,  all.  He  does  not  exchange  a • 
single  word  with  any  of  the  other  inmates.  He  has  never  shown  the 
slightest  sign  of  friendship  for,  or  sympathy  with,  anyone.  He  has  a i 
brother  and  he  has  sisters,  but  he  never  speaks  of  them,  never  asks  for  ; 
them,  never  takes  any  interest  in  them.  ' 

y He  cannot  understand  why  he  is  being  kept  in  an  asylum.  He  has  , 
never  even  suspected  that  his  hallucinations  and  the  resulting  delirious  x 
ideas  are  a morbid  product.  He  is  absolutely  convinced.  To  the  great  = 
injustice  that  is  done  him  by  persecuting  him  in  such  a ferocious  fashion 
there  is  added  the  other  injustice  of  keeping  him  shut  up  in  the  asylum, 
so  that  he  may  be  delivered,  bound  hand  and  foot,  into  the  power  of  those  ; 
who  are  tormenting  him.  Every  time  he  sees  me  as  I go  my  rounds  I 
hear  these  words  repeated  : ‘ Send  me  away  ; do  not  be  unjust  to  me.  I ( 
am  not  insane  ; I have  never  done  harm  to  anyone.  I have  no  fault  to  | 
reproach  myself  with.  Give  me  my  liberty.’  ) 

^ This  man  remained  in  the  asylum  in  this  condition  for  more  than  four  j 
years.  There  was  no  further  modification  or  evolution  of  his  delirium,  j 
and  no  transformation.  There  was  no  phenomenon  of  mental  decadence. 
As  he  never  managed  to  learn  who  his  persecutor  was,  he  remained  in 
doubt  and  anxious  to  find  out.  Though  he  was  strong  and  healthy,  he 
always  refused  to  work. 

He  was  transferred  to  another  asylum. 


Observation  XVIII. — K.  Maria  Luisa  di  Ferdinando,  thirty-three 
years  of  age,  single,  born  at  Naples  of  a Neapolitan  mother  and  a Swiss 
father,  was  admitted  into  the  Naples  Asylum  on  May  lo,  1903.  In  the 
Questor’s  report  it  was  said  that  Miss  K.  had  been  found  in  a grotto  at 
Capodimonte,  where  she  had  been  living  for  some  days. 

She  herself  tells  that  at  the  age  of  fourteen  she  used  frequently  to  get 
up  at  night,  and  remain,  for  many  hours,  writing,  putting  the  house  to 
rights,  or  doing  some  other  work,  although  the  next  morning  she  would 
have  no  remembrance  of  anything  she  had  done  during  the  night 
(somnambulism).  Her  father,  for  many  years  a sufferer  from  epilepsy. 


PARANOIA 


593 


was  very  much  troubled  about  this  somnambulism  of  his  daughter,  and 
consulted  various  physicians.  We  do  not  know  what  treatment  they 
practised,  but  certainly  in  subsequent  years  she  was  not  subject  to  these 
disturbances.  The  patient  also  asserts — and  it  may  well  be  believed — that 
she  showed  notable  precocity  in  her  mental  evolution.  At  the  age  of 
ten  or  eleven  years  she  already  understood  a great  many  matters  that  her 
companions  did  not  understand  even  at  eighteen.  She  had  a passion  for 
literary  studies,  in  which  she  would  have  perfected  herself  had  her  father 
and  her  grandmother  not  prevented  her.  She  has  always  aspired  to  make 
herself  independent,  and  to  attain  a position  in  which  she  should  not 
require  the  aid  of  anyone. 

A degree  in  literature  would  have  conferred  on  her  the  independence 
that  she  sought,  but,  she  says,  her  people  opposed  that  course,  perhaps 
with  good  intentions,  but  certainly  with  very  bad  effect,  for  her  troubles 
are  in  great  part  due  to  her  not  having  an  independent  position.  Further, 
was  it  not  a pity  that  all  her  moral  energy,  of  which  from  her  infancy  she 
had  given  indisputable  proof,  should  remain  fruitless,  whilst,  had  it  been 
well  guided  or  had  only  no  obstacles  been  placed  in  the  way,  it  might 
have  borne  fruit  to  her  own  benefit  and  that  of  others  ? (High  estimation 
of  one’s  own  powers,  the  germ  of  megalomania).  At  the  early  age  of  four- 
teen she  began  to  have  a vague  and  indeterminate  idea  that  some  person 
or  persons  with  whom  she  was  in  daily  contact  were  persecuting  her,  or, 
at  least,  were  out  of  sympathy  with  her  and  desirous  to  cause  her  trouble, 
to  place  obstacles  in  the  way  of  all  the  manifestations  of  her  activity,  and 
even  to  bring  her  into  disrepute.  According  to  her  own  story,  she  has 
always  had  a certain  clairvoyance  that  has  enabled  her  to  divine  matters 
even  though  but  distantly  related  to  herself  or  her  family.  Once  when 
her  father  received  an  anonymous  letter  which,  as  she  says,  contained 
very  disagreeable  matter,  she  thought  that  she  could  guess  from  whom 
it  came  ; and  from  that  time  on  she  has  suspected  that  a current  of 
feeling  hostile  to  herself  was  directed  against  her  by  a certain  person  and 
by  a certain  family.  Until  the  death  of  her  grandmother,  with  whom  she 
lived,  however — that  is  to  say,  until  she  had  reached  the  age  of  twenty- 
seven — she  had  nothing  more  to  complain  of  than  the  tacit  opposition  made 
by  those  of  her  own  household  to  everything  that  she  initiated — a species 
of  passive  resistance,  quite  invincible,  that  was  opposed  to  her  free 
activity.  After  her  grandmother  died  matters  began  to  become  com- 
plicated. She  had  to  return  to  her  father’s  house,  where  she  lived  for 
two  years  in  continual  discomfort,  sometimes  being  violently  opposed  by 
her  stepmother.  Her  father  was  forced  to  seek  a home  for  her  in  the  house 
of  a family  in  the  Vasto  quarter.  There  she  lived  in  comparative  content- 
ment until  she  commenced  to  notice  a very  strange  phenomenon  : as 
soon  as  ever  an  idea  was  formed  in  her  mind,  she  heard  it  repeated  by  the 
persons  around  her.  We  shall  see  how  she  explained  the  phenomenon 
to  herself  and  how  she  adopted  the  theory  of  suggestion,  which  made 
everything  clear  to  her.  At  that  time,  however,  she  was  convinced  that 
all  the  persons  with  whom  she  came  in  contact,  known  or  unknown  to  her, 
in  the  streets  or  in  the  tenement  where  she  lived,  were  one  and  all  reading 
her  thoughts  aloud.  This  was  a condition  of  matters  that  she  could  not 
bear,  for  it  was  impossible  for  her  to  keep  anything  secret.  The  profane 
eye  was  penetrating  into  the  inmost  recesses  of  her  consciousness,  and 
detecting  the  ideas  that  passed  through  it,  the  plans  that  were  being 
matured  in  it,  and  the  remedies  that  were  perchance  thought  of.  In  this 
way  the  one  thing  that  up  till  then  she  had  thought  to  be  most  peculiarly 
and  indisputably  her  own — namely,  her  consciousness — had  become 
public  property. 

It  seemed  to  her  impossible  that  this  state  of  affairs  could  last  long, 
and,  above  all,  it  appeared  impossible  that  she  should  suffer  it  for  any 

38 


594 


PSYCHIATRY 


length  of  time.  In  the  hope  of  escaping  from  what  had  become  an  abso- 
lute martyrdom,  she  changed  her  residence  and  left  the  shop  in  which  she 
worked,  but  all  in  vain.  Her  brain  continued,  to  be  like  an  open  book 
which  all  could  read.  • As  the  patient  herself  wittily  expressed  it,  it  was 
the  only  book  that  even  the  illiterate  could-  read. 

The  idea  then  occurred  to  her  to  consult  by  letter  a hypnotist  in  the  I 
outskirts  of  Naples,  from  whom  she  had  already  received  various  hand-  j 
bills.  She  applied  to  him,  asking  him  to  put  her  into  a state  that  would  j 
enable  her  to  resist  this  new  and  strange  form  of  persecution,  or  to  suggest  I 
a means  of  interposing  .a  diaphragrn  between  her  thought  and  the  clair-  j 
voyance  of  those  who  were  reading  it.  She  derived  no  benefit  from  this 
proceeding  ; on  the  contrary,  she  believes  that  the  step  she  then  took 
was  fatal,  because  very  probably  the  hypnotist,  instead  of  assisting  her,  | 
entered  also  into  the  plans  of  her  persecutors.  She  changed  her  residence  | 
Qnce  more,  but  in  her  new  home  her  thoughts  were  read  just  as  before,  ! 
and  she  finally  decided  to  leave  Naples  and  go  to  Palermo.  The  change  i 
of  scene,  however,  brought  no  change  of  fortune.  At  Palermo  she  had  I 
no  peace  even  for  the  first  twenty-four  hours.  Her  thoughts  were  read 
even  more  persistently  than  before,  and  her  brain  had  not  a moment’s  I 
rest ; for  on  the  one  hand  she  could  not  hinder  the  flow  of  ideas,  more  or 
less  strange  in  character,  that  passed  rapidly  through  her  mind  in  constant 
succession,  and,  on  the  other  hand,  she  could  not  close  her  ears  to  the  | 
voices  of  the  persons  who  repeated  to  her  what  she  was  thinking.  Then 
another  strange  thing  happened.  She  applied  to  an  employment  agency  j 
to  get  a post  as  governess  in  some  good  family  ; the  post  was  promised 
to  her,  and  she  was  told  to  call  again  within  a few  days.  She  did  so,  but 
to  her  surprise  she  perceived  that  the  persons  in  charge  of  the  agency  ■< 
were  making  fun  of  her,  putting  her  off  from  day  to  day  with  doubtful  |j 
promises,  and  screwing  up  their  faces  in  mimicry  of  her.  She  had  a :| 
suspicion,  which  she  thought  was  well  founded,  that  her  enemies  had  : 
already  been  giving  unfavourable  reports  of  her  ; and  so  it  seemed  to  her  ; 
useless  to  prolong  her  sojourn  in  Palermo,  where  she  had  not  found  peace  |; 
and  had  not  succeeded  in  getting  work.  She  therefore  returned  to  Naples,  1 
and  as  soon  as  she  reached  that  city  she  went  to  the  office  of  the  Questor  ! 
to  protest  against,  and  to  ask  public  protection  from,  that  unworthy  and 
inhuman  persecution.  One  of  the  police  officials  advised  her  to  live  for  ,| 
a month  in  a house  where  he  could  look  after  her.  She  agreed,  .but  not  J 
even  in  that  house,  under  the  very  eyes  of  the  Questor’s  officers,  didp 
matters  change.  Driven  to  despair  by  what  was  happening  to  her,  andiji 
having  lost  all  confidence  in  such  assistance  as  could  be  obtained  from  the 
authorities,  she  thought  of  going  away  to  some  district  with  as  few  inhabi- 
tants as  possible,  where  it  would  not  be  difficult  for  her  to  avoid  meeting  ’ ' 
any  human  being.  For  some  days  she  wandered  about  the  lanes  of 
Capodimonte,  taking  shelter  at  night  in  a sort  of  grotto,  and  having  little 
or  no  food.  In  the  grotto  she  was  found  by  the  police,  and  was  sent  to 
the  asylum. 

There  she  has  behaved  very  well  from  the  day  of  admission,  although  ; 
she  has  continually  protested  against  the  loss  of  her  liberty,  of  which,  she 
declares,  no  one  had  any  right  to  deprive  her.  She  displays  intelligence 
sufficiently  evolved  and  highly  cultivatecl./  She  speaks  and  writes  . 
correctly  both  Italian  and  French.  She  has  a slight  knowledge  of 
German.  She  has  a very  considerable  acquaintance  with  history,  and  i 
she  shows  that  she  has  read  many  books.  As  to  her  own  past,  she  can  i 
relate  even  the  slightest  particulars,  and  she  discusses  the  details  of  her  i 
misfortunes  with  a wonderful  wealth  of  argument.  When  she  begins  to  | 
talk  it  is  difficult  to  restrain  her,  or  to  get  her  to  change  the  subject  of  her  | 
discourse.  She  continues  her  reasonings  without  taking  the  slightest  i 
account  of  the  interruptions  and  the  observations  of  the  interlocutors. 


PARANOIA 


595 


She  distrusts  everybody,  including  the  superintendent  and  the  physicians, 
in  whom  she  had  a certain  degree  of  confidence  to  begin  with.  In  the 
asylum,  however,  the  reading  of  her  thoughts  has  ceased.  Since  the  day 
of  her  admission  she  has  never  again  heard  the  echo  of  her  ideas  on  the 
lips  of  others  ; but  this,  she  says,  is  easily  explained  by  the  fact  that  her 
enemies  cannot  pass  the  threshold  of  the  asylum. 

She  has  changed  her  opinion  as  regards  the  thought-reading.  At 
present  she  is  convinced  that  it  was  not  really  a case  of  thought-reading, 
but  of  suggestion  practised  upon  her  by  others.  By  the  influence  of  a 
certain  woman  whom  she  considers  to  be  her  enemy,  or  of  the  hypnotist 
whom  she  once  consulted,  or  of  both  together,  all  persons  with  whom  she 
came  in  contact  gained  the  power  of  imposing  their  own  thoughts  upon  her 
at  a given  moment.  It  is  not,  as  she  formerly  thought,  that  others  read 
her  thoughts  ; what  really  happens  is  that  she  is  forced  to  think  the 
thoughts  of  others.  Thus  she  gets  an  explanation  of  how  other  people 
knew  what  she  was  thinking,  and  how  she  was  unable  to  change  the  course 
of  her  own  thoughts  at  will.  From  the  last-mentioned  disturbance  she  still 
suffers.  If  she  commences  to  read  a book,  some  idea  quite  extraneous  to 
the  subject  she  is  reading  will  suddenly  come  into  her  mind  and  fix  itself 
there  so  that  it  cannot  be  driven  out.  She  continues  to  read,  but  does  not 
understand ; and  if  at  any  moment  she  thinks  that  she  understands  and 
reads  further,  at  the  end  of  the  paragraph  or  of  the  chapter  she  finds  that 
she  has  entirely  forgotten  all  that  she  has  read.  Furthermore,  the  patient 
will  not  admit  that  this  imperious  idea  that  thus  recurrently  interrupts 
her  reading  may  possibly  arise  spontaneously  in  her  own  brain.  She  is 
convinced  that  it  is  imposed  upon  her  by  suggestion.  Not  long  ago  she 
concluded  a letter  to  the  superintendent  in  the  following  manner : 

‘ At  the  moment  I am  writing  the  present  note  I feel  myself  being  sub-^ 
jected  to  suggestion.  Who  is  the  person  practising  suggestion  upon 
me  ? and  how  is  it  that  he  dares  to  take  the  liberty  to  make  use  of  a person 
who  does  not  belong  to  him  ?’ 

On  this  theme  of  suggestion  she  insists  also  in  a letter  addressed  to 
her  father.  We  quote  here  the  most  interesting  part  of  it  : 

‘ Dear  Father,  I should  like  most  urgently  to  see  you.  The  visitors’  room 
here  is  open  from  lo  a.m.  till  noon  on  Tuesdays,  Thursdays,  and  Sundays. 

I intend  to  speak  on  subjects  that  will  not  in  any  way  be  tiresome  to 
you.  I have  written  to  the  Consul  asking  him  to  protest  against  an  abuse 
that  is  a blot  upon  a civilized  age,  but  he  takes  no  notice,  so  that  I do 
not  know  what  to  think  of  his  behaviour. 

‘ For  the  past  six  years  I have  been  a victim  of  suggestion.  I cannot 
at  all  understand  how  the  person  suggesting  can  take  the  liberty  of 
imposing  himself  upon  me,  who  am  not  dependent  upon  anyone  at  all. 
Not  only  that,  but  I should  like  to  know  what  right  a miserable  police 
agent  has  to  follow  me  about  everywhere.  I have  no  enemies,  because 
I have  never  made  any  ; and  those  few  that  I might  have  had  were 
offended  by  others  than  myself. 

‘ With  my  own  small  savings,  a little  goodwill,  and  trust  in  God,  I 
should  have  been  able  to  solve  that  famous  problem  how  to  gain  my 
livelihood  honestly ; but  that  malignant  genius  that  has  always  presided 
over  my  destiny  has  once  again  crossed  my  path.  . . . 

‘ I do  not  wish  to  be  subjected  to  suggestion.  I do  not  admit  the  will 
of  anyone.  I should  like  to  know  my  enemy  ! ! I If  I decide  to  drop  my 
name  and  my  family  like  a pariah,  I still  wish  to  be  certain  of  recovering 
that  true  liberty  which  every  free  creature  has  a right  to  claim  in  a country 
where  there  is  liberty  of  thought,  freedom  of  the  press,  liberty  of  action  and 
of  speech.  Let  them  tell  me  who  is  my  persecutor,  and  you  will  have  no 
more  trouble — neither  you,  nor  he,  nor  I ! 


38—2 


596 


PSYCHIATRY 


‘ I am  suffering  ! The  air  of  this  place,  the  rules  and  regulations,  and 
my  surroundings,  do  not  suit  me  at  all.  Here  we  are  almost  all  poor 
people,  and  on  the  day  when  we  leave  we  shall  surrender  in  crowds,  as 
the  Milanese  did  when  they  went  out  of  Milan,  only  we  shall  not  have  the 
rope  around  our  necks  unless  we  put  it  there  ourselves. 

‘ Comets  drag  behind  them  a luminous  tail,  but  the  falling  stars 
press  on  and  fall  exhausted  when  they  have  no  longer  the  force  to  | 
continue  their  course.  I 

‘ Why  does  Professor  Bianchi  take  into  his  asylum  people  who  are  I 
victims  of  suggestion,  and  treat  them  as  insane  ? . . . | 

‘ For  the  space  of  so  many  years  you  have  borne  an  enormous  and 
heavy  burden  on  your  poor  shoulders,  being  a poor  epileptic  ; but  my  ; 
case  is  different.  I have  always  had  a certain  amount  of  intelligence,  ; 
and  when  I was  little  the  correctness  of  my  mode  of  thought  astonished  I 
people  ! Dear  father,  I expect  you  on  Thursday,  and  I hope  that  you  i 
will  not  fail  me.  On  my  part,  I promise  that  I shall  not  give  you  any 
more  trouble,  and  when  I have  learned  the  name  of  my  enemy  I shall 
annoy  you  no  further. 

‘ Who  can  tell  who  it  is  that  is  making  me  a victim  of  suggestion,  and 
why  he  is  troubling  us  ?’ 

She  is  not  given  to  religious  practices,  although  she  is  a believer.  She  | 
was  brought  up  in  the  Protestant  faith,  to  which  she  has  ever  adhered. 
She  was  never  fond  of  company  ; her  ideal  was  to  be  alone  and  indepen- 
dent. For  that  reason  she  has  never  even  thought  of  loving  a man  (as  , 
a rule,  congenital  paranoiacs  do  not  love).  Matrimony  never  entered  into 
her  calculations  nor  even  into  the  field  of  her  views.  | 

In  the  following  observation  I report  an  example  of  paranoia  ' 
with  delirium  both  of  grandeur  and  of  persecution,  rapidly  followed  , 
by  mental  decay.  ! 

Observation  XIX. — Amah  R.,  fu  N.,  of  Naples,  forty-one  years  old, 
bachelor,  was  received  into  the  Provincial  Asylum  of  Naples  on  October  23,  : 
1897.  We  know  little  of  his  family  history.  Of  his  earlier  life  two  facts  of  I 
some  importance  are  known — namely,  that  at  twelve  years  old  he  suffered  ( 
from  the  so-called  ‘ chiodo  solare,’  or  sunstroke,  and  that  when  he  was  j 
about  thirty  he  was  tried  and  condemned  to  four  years’  imprisonment 
for  fraud.  He  had  hardly  regained  his  liberty  when  he  was  taken  to  the  \ 
asylum,  suffering  from  a classic  delirium  of  persecution  and  from  very  j 
marked  exaltation  of  the  psychic  personality,  gradually  developing  into  a 
concrete  and  systematized  delirium  of  grandeur.  In  the  very  short  interval 
between  his  liberation  from  gaol  and  his  confinement  in  the  asylum  he 
had  very  little  food,  often  being  forced  to  live  on  a penny  per  day.  The 
delirium  of  persecution  had  its  origin  in  two  real  facts — his  condemnation 
for  fraud,  and  his  implication  in  the  case  of  the  Banca  Romana,  having 
foolishly  lent  his  name  to  one  of  the  very  numerous  speculations  by  which 
others  profited.  As  the  result  of  his  trial  and  imprisonment,  he  lost  his 
former  position  as  representative  of  a foreign  commercial  house.  He 
became  irritable  and  weak  from  the  struggle  that  he  consequently  had  in 
order  to  meet  the  wants  of  his  daily  life,  and  there  arose  in  his  mind  the 
suspicion  that  his  trial,  imprisonment,  and  loss  of  position  were  the  work 
of  enemies.  This  suspicion  became  a conviction  when  he  was  confined 
in  the  asylum.  The  thing  was  perfectly  clear  : now  that  they  had  de- 
stroyed his  honour  and  rendered  it  impossible  for  him  to  gain  a livelihood, 
his  enemies  were  putting  him  into  a position  that  would  prevent  him 
from  speaking.  \Mio  those  enemies  of  his  were  he  has  never  definitely 


PARANOIA 


597 


said.  He  has  had  his  suspicions — perhaps  they  were  the  high  personages 
implicated  in  the  case  of  the  Banca  Romana — but  he  has  never  troubled 
himself  very  much  to  find  out  the  names  of  his  enemies.  His  own  personal 
interest  has  been  absorbed  by  another  general  question,  more  worthy  of 
an  intellect  like  his,  and  more  fitted  to  move  his  noble  mind — the  question 
of  the  corruption  of  justice.  His  own  case  is  a trifling  and  miserable 
incident  which  he  would  forget  if  the  deprivation  of  his  liberty  did  not 
constantly  remind  him  of  it.  The  essential  fact  is  that  there  is  no  longer 
any  justice  in  the  world.  I give  below  a few  extracts  from  his  numerous 
writings  on  this  theme,  which  are  full  of,  and  indeed  overcrowded  with, 
high-sounding  phrases  and  sentences  and  reminiscences  of  his  own 
favourite  authors  : 

' At  all  times  and  in  all  places  it  has  been  the  custom  to  represent  . 
justice  as  a virgin  holding  in  her  hands  a balance  in  stable  equilibrium.  . . . 

‘ To-day  the  weight  is  on  the  side  of  gold  or  of  iron,  as  in  the  days  of 
Brennus  !!!... 

‘ O ye  of  little  understanding  !!!... 

‘ From  Babylon  to  Troy,  from  Troy  to  Rome,  it  was  always  for  justice, 
for  equanimity,  for  the  sacred  right  of  man  to  constitute  himself  into 
Societies,  that  fights  were  fought  and  the  blood  was  shed  of  so  many 
martyrs,  so  many  heroes  of  the  freedom  of  thought.  . . . 

‘ But  to-day  the  words  Law,  Justice,  Jurisdiction,  Logic,  Gratitude, 
Ethics,  Rights,  are  one  and  all  void  of  meaning. 

‘ Luther,  Calvin,  Zwingli,  the  Council  of  Trent  (and  the  last  wonderful 
Council  of  Pio  IX.)  put  an  end  to  the  abuse  of  thought,  to  the  base 
bartering  of  conscience.  But  to-day  conscience  is  subjective,  just  as 
Morality  is  subjective  ; Abuse,  Injury,  and  Oppression  are  tacitly  sanc- 
tioned in  the  pages  of  the  Codes  and  of  the  Pandects.  . . . 

‘ At  the  end  of  the  Revolution  of  ’79  and  ’93,  with  the  Vandacci  there 
came  the  Albigeri,  but  that  did  not  put  an  end  to  those  abuses  and 
violations  that  for  a time  were  called  the  “ Denial  of  God  and  the  shame 
of  the  nations.”  . . . 

‘ Poor  humanity  ! It  has  fallen  from  the  seventh  Heaven,  and  we 
to-day  from  that  height  can  perceive  only  Commercialism,  Confusionism, 
and  base  trafficking  in  conscience.  . . . 

‘ What  is  the  good  of  playing  with  words  ? Intentions  are  too  manifest 
and  deeds  are  too  clearly  seen.  Injustice  wraps  herself  in  a purple  robe, 
and  he  who  happens  to  be  innocent  is  made  to  appear  guilty,  just  as  “ HE 
who  was  innocent  of  everything  ” is  ostracized  and  made  the  scapegoat, 
while  malefactors  receive  honour  and  applause.  . . . 

‘ After  the  nineteenth  century  has  run  its  course,  or,  better  still,  au 
fin  du  siecle,  Justice  is  trafficked  in  and  Judges  are  corrupted  with  money  ; 
vvith  good  reason  may  WE  say  : “ Humanity  is  on  the  verge  of  dissolu- 
tion.” . . . 

‘ To-day  the  Auri  Sacra  Fames  prevails  over  Justice.’ 

Note  the  expressions  ‘ Judges  are  corrupted  with  money,’  ‘ Scapegoat  ’ 
(which  he  misspells),  and  ‘ The  innocent  is  made  to  appear  guilty  ’ ; 
these  express  clearly  his  conviction  that  he  has  been  made  to  pay  the 
penalty  for  others.  Note  the  word  ‘ WE’  in  large  letters,  with  which  he 
designates  his  own  hypertrophied  personality. 

He  shows  no  concern  for  himself,  except  in  protesting  against  those 
who  have  deprived  him  of  liberty. 

‘ Because,  in  fact,  though  we  had  not  a morsel  of  brown  bread  to 
appease  our  hunger,  or  a roof  to  shelter  us  from  the  hail  and  the  cold, 
WE,”  intelligent  and  free  creatures,  should  become  for  ever  rich,  were 
justice  to  prevail  in  this  kingdom,  and  were  we  in  possession  of  our  own 
proper  dignity.’ 


598 


PSYCHIATRY 


The  deprivation  of  his  liberty  weakens  him  physically,  besides  humili- 
ating  him  morally  : 

‘ I feel  myself  oppressed  beyond  measure  by  the  cruel  vicissitudes  of 
life,  and  my  hand  trembles  as  a result  of  the  continuous  imprisonment  to 
which  I have  been  condemned  by  the  barbarity  of  men.  . . 

He  does  not  always  write,  however,  in  this  sad  and  almost  resigned  tone. 
Sometimes  he  is  proud  or  even  violent,  especially  when  he  writes  to  the 
‘ Man-Superintendent  ’ and  to  the  assistant  physicians,  who,  he  thinks, 
prevent  him  from  leaving  the  asylum.  Here  is  an  example  : 

" YOU  ARE  MISERABLE  WRETCHES  ! and  if  insults  were  not  the 
weapons  of  those  who  are  in  the  wrong  “ should  hurl  a mountain  of 
them,  tens  of  thousands  of  them,  at  you.  Of  sufferings,  moral  and 
physical,  of  pinpricks  and  poor  old  women’s  tattle,  of  characterless  indi- 
viduals, I have  now  enough  to  fill  all  Italy.  . . .’ 

All  great  men  have  been  called  madmen,  and  he  among  the  others. 

‘ Socrates,  Confucius,  Schiller,  Columbus,  Galileo,  God  Himself  in  the 
figure  of  Christ  the  Man-God,  were  honoured  with  a Crown  of  Laurel  in 
being  called  “ MADMEN.”  We,  not  to  say  I myself,  have  been  honoured 
also  by  being  called  insane.’ 

When  he  saw  that  his  protests  were  unheeded  and  that  there  was  no 
word  of  his  being  allowed  to  leave  the  asylum,  he  began  to  think  the  world 
could  not  last  with  so  much  iniquity  in  it  and  such  perversion  of  human 
justice,  and  that  some  day  or  other  a general  cataclysm  would  reduce  it 
to  dust.  From  the  day  on  which  that  idea  flashed  across  his  mind  he 
has  been  trying  to  find  out  from  the  movements  of  the  stars  and  the 
variations  of  temperature  and  atmospheric  pressure,  the  precursory  signs 
of  the  cataclysm  of  the  world,  the  date  of  which  he  fixes  from  time  to 
time.  Thus  he  has  become  an  astronomer,  and  at  intervals  he  sends  out 
his  bulletins.  I give  one  of  them  here  : 

‘ To  the  Man-Superintendent  and  all  the  Doctors. 

‘ Understand  ! 

‘ Repetition  is  a good  thing. 

‘ General  Bulletin  For  The  World,  to  be  issued  regularly  during  the 
UNIVERSAL  CATACLYSM.  The  Faculty  of  Astronomy,  Bacteriology, 
and  Star-Meteorology  (Ranieri  Amalfitano  fu  Nicola)  in  the  Nubilous  and 
Nebulous  system  of  charges  and  transferences  : 

‘ PREDICTS  : To-day,  19th  February,  1899,  for  23rd  February, 
1899,  THE  DATE  OF  COMMENCEMENT  OF  THE  UNIVERSAL 
CATACLYSM. 

‘ 19th  February,  1899,  continuing  1900,  and  becoming  permanent  in 
1901. 

‘ I,  Faculty,  call  God  only  to  witness. 

‘ You,  respectable  spectators  and  spectatresses,  also  conscripts,  have 
nothing  more  to  do  than  to  give  me  your  courteous  attention. 

‘ ATTENTION. 

‘ ^th  October,  1899. — At  Naples : Storm  and  thunder — Sky  over- 
clouded— Passing  clouds — Sun  at  intervals  of  very  short  duration. 

‘ $th  October,  1899. — Northern  Italy : At  Belluno,  Udine,  and  on  the 
Venetian  Coast  and  neighbourhood,  including  Misurina — Storm  and 
thunder  at  intervals — Banks  of  passing  clouds — Opal  sun  at  interv^als 
during  the  day. 

‘ ^th  October,  1899. — In  the  district  of  Genoa,  also  at  Monte  Rosa  and 
at  the  Picco  di  Tre  Signori  : Storm  and  devastation  with  thunder  of 
short  duration — Sun  opaline — Sky  cloudy — Zic-zac  clouds. 

‘ N.B. — Write  Zic-zac  with  a “ c ” instead  of  a “ g ” : the  reason  is 
that  the  term  is  atmospheric.’ 


PARANOIA 


599 


He  continues  in  this  way  with  predictions  for  all  the  towns  of  Italy 
and  for  all  districts  of  Europe  and  America.  _ 

But  his  meteorological  bulletins,  his  ethical  addresses,  and  his  apos- 
trophes and  imprecations  soon  became  stereotyped.  For  the  past  three 
or  four  years,  after  a period  of  florid  paranoia  that  lasted  a little  more 
than  two  years,  the  patient  has  invariably  repeated  himself  in  his  dis- 
courses and  writings.  No  matter  what  the  question  put  to  him,  his 
answer  inevitably  commences  thus  : 

‘ From  Babylon  to  Troy,  from  Troy  to  Rome,  it  was  always  for  justice, 
for  equanimity,  for  the  sacred  right,  etc.  . . .’ 

Then  he  goes  on  : ‘ Luther,  Calvin,  Zwingli,  etc.’ 

When  he  gets  out  of  this  tangle,  not  a word  of  his  speech  can  be  under- 
stood, so  great  is  his  intellectual  confusion.  I give  here  an  extract  from 
a recent  discourse,  as  it  was  taken  down  in  shorthand. 

After  the  usual  ‘ From  Babylon  to  Troy,  from  Troy  to  Rome,’  etc., 
he  goes  on  : 

‘ To  whom  would  you  give  an  Astronomical  Observatory  if  not  to  me  ? 
I challenge  anyone  ; I know  everything  about  the  subject.  My  Bulletins 
prove  it.  The  madness  of  this  world  has  prescribed  for  women  Riding 
Shoes,  Black  Merino  Gowns,  Scarlet  Belts,  Ornamental  Insteps,  Gold 
Lace,  Tight  Waists,  and  Astronomical  Caps.  This  is  the  present  fashion, 
as  a neighbouring  Outfitter,  Canestrelli,  has  known  ever  since  1892.  One 
open-work  Black  Straw  Hat,  triangular  and  cocked.  Lire  36.  That  is  the 
feminine  Astronomical  Cap.  Fashion  for  women  of  the  ordinary  ranks  : 
Scarlet  Dress  with  mantelet ; Bodice  with  Yellow  Breast  and  Scarlet 
Trimmings.  In  summer  they  should  be  dressed  in  lily-white  or  lilac. 
The  figure  X in  my  Bulletin  is  for  the  horizontal,  and  the  breasts  are 
scarlet,  having  maps — that  is  to  say,  handkerchiefs  that  can  be  worn  on 
the  chest.  For  men,  garments  of  Black  Cheviot,  Scarlet  Sash,  Black 
Straw  Hat  with  Scarlet  Ribbon  or  the  Astronomical  Cap  d la  Ranieri,  such 
as  is  worn  by  an  Engineer  who  comes  here.’ 

All  his  mental  faculties  are  reduced  to  this  fanciful  nonsense.  The 
affections  of  the  patient  are  almost  dead.  He  has  a vague,  faint,  and 
colourless  recollection  of  his  mother.  He  never  troubles  about  his  rela- 
tives, does  not  know  whether  any  of  them  are  alive,  and  says  that  in  any 
case  he  has  no  need  of  them. 

Religious  paranoia  has  become  very  rare.  In  comparison  with 
the  deliria  of  persecution  and  of  grandeur,  which  are  the  echoes  of 
the  stronger  emotions  that  stir  the  modern  mind — the  desire  for 
fortune  and  enjoyment,  and  the  fear  of  not  attaining  these  owing  to 
the  endless  difficulties  met  with  in  the  social  environment — religious 
delirium  is  ever  becoming  rarer  in  proportion  as  the  aspiration  of 
man  towards  the  Divinity  disappears  from  amidst  the  masses  of 
the  people,  and  as  the  reality  of  life  takes  a greater  hold  of  the 
mind  than  the  hope  of  a supernatural  Paradise.  Amongst  the 
Italians,  religious  belief  has  been  much  weakened  and  the  animistic 
trend  of  the  mind  is  interfered  with  by  the  pressure  of  life.  Religious 
paranoia,  therefore,  is  rarely  seen,  even  in  so  large  and  populous 
an  asylum  as  that  at  Naples.  This  fact  is  a further  proof  that  the 
deliria  of  paranoia  strike  their  roots  into  the  actual  currents  of 
popular  thought  and  belief,  not  into  those  that  have  completely  dis-. 


6oo 


PSYCHIATRY 


appeared  even  from  the  lowest  social  strata.  For  a like  reason, 
lycanthropy  has  disappeared,  and  the  legend  of  the  werewolf 
furnishes  very  few  cases  indeed. 

The  religious  paranoiac  is  usually  a mystic  megalomaniac.  He 
passes  through  a period  of  asceticism.  He  goes  to  church  a great 
deal,  listens  to  the  sermons,  confesses  often,  takes  the  Communion, 
fasts,  and  inflicts  punishments  on  the  flesh  in  every  conceivable 
manner  in  order  to  purify  himself  of  some  fault  of  adolescence.  If  he 
is  illiterate,  he  concentrates  all  his  attention  on  the  images  of  saints, 
either  at  home  or  in  church.  His  whole  life  is  centred  around  them  ; 
his  imagination  becomes  exalted  by  gazing  upon  and  kissing  them. 
A species  of  intense  fetishism  gives  the  intonation  to  his  psychic 
being.  By  degrees  the  subject  loses  his  contact  with  reality, 
neglecting  his  duties  for  religious  exercises,  and  becoming  at  first 
indifferent,  then  haughty  and  intolerant  towards  his  family.  His 
affection  for  the  persons  dear  to  him  is  at  first  weakened,  then  dis- 
appears entirely,  its  place  being  taken  by  complete  indifference. 
His  nutrition  is  undermined  by  fasts,  but  at  the  same  time  a sense 
of  spiritual  comfort  masters  him,  a great  hope  and  a profound  con- 
solation encourage  him  to  persevere.  He  knows  that  he  is  under- 
stood, and  he  is  sure  that  his  prayers  are  heard  by  God  and  the  . 
saints.  An  inward  spiritual  joy  detaches  him  more  and  more  from  , 
the  pleasures  and  relationships  of  worldly  life.  ; 

Meanwhile,  sensory  disturbances  begin  to  make  their  appear-  ; 
ance.  He  imagines  that  he  sees  some  new  feature  in  the  physiog- 
nomy of  an  image.  Christ  has  made  him  a sign  with  the  head  or  ? 
the  Madonna  has  moved  her  lips  or  made  a sign  with  the  eyes — ' 
there  is  now  no  doubt  of  that.  His  dream  has  been  realized,  and  , 
already  he  is  in  direct  communication  with  the  saints  in  heaven.  - 
To  these  illusionary  disturbances,  produced  by  the  ordinary  ' 
mechanism,  there  are  added  auditory  and  visual  hallucinations.  ■ 
In  most  cases  visual  hallucinations  predominate.  The  images  to  \ 
which  the  fervent  prayers  have  been  addressed  for  months  past  * 
appear  to  him — first  in  sleep  as  a rule,  and  afterwards  when  he  is  j 
awake.  They  do  not  speak,  but  should  they  do  so  their  words  are 
an  encouragement  or  a command.  These  apparitions,  or,  rather, 
visual  hallucinatory  images,  however,  are  sufficient  to  definitely 
confirm  the  delirium.  He  is  the  Elect  of  God,  the  Word  Incarnate, 
the  Messiah,  the  New  Messiah,  the  Christ,  the  Antichrist. 

There  is  an  easy  progress  from  the  delirious  conception  to  some 
particular  attitude,  and  from  that  attitude  to  conduct.  Life  becomes 
manifested  in  terms  of  the  new  ideas,  and,  according  to  individual 
tendencies,  we  get  the  preacher,  the  hermit,  the  reformer,  the  dis- 
penser of  grace,  the  worker  of  miracles,  the  inspired  one,  or  the 
diviner  of  the  future. 

If  the  delirium  develops  in  an  educated  subject  who  is  much 
given  to  study,  all  his  talent  and  all  his  culture  are,  by  a process 


PARANOIA 


6oi 


of  unconscious  cerebration,  put  at  the  service  of  the  new  ideas, 
which  he  maintains  with  great  wealth  of  argument,  and  with  keen 
and  inexhaustible  dialectic  power.  He  has  a conviction  against 
which  the  weapons  of  logic  and  culture,  or  the  authority  of  any 
ahenist  are  useless.  The  transformation  of  the  personality  in  the 
direction  of  religious  and  political  reform  follows  as  a fatal  neces- 
sity. The  social  problem,  which  holds  the  attention  of  men’s 
minds  much  more  strongly  to-day  than  it  did  in  the  past,  plays  its 
own  part  in  the  evolution  of  religious  paranoia,  and  the  delirium 
of  the  primitive  and  uneducated  subjects,  which  is  exclusively 
mystic,  becomes  a mystic  humanitarian  or  social  delirium  in  this 
second  class  of  sufferers. 

Here  also  the  evolution  of  the  delirium  is  more  or  less  slow. 
Above  all,  if  those  hallucinations  that  always  hasten  on  mental 
decay  should  intervene,  the  simple  reformer  loses  his  last  points 
of  contact  with  reality  and  with  his  intellectual  patrimony,  such 
as  it  was  prior  to  the  malady,  and  becomes  the  Messiah,  God, 
Christ,  the  Lord  of  the  world,  etc.  In  these  cases,  as  a rule,  no 
true  delirium  of  persecution  is  developed.  What  we  get  are  rather 
persecutory  episodes  determined  by  the  calamitous  circumstances 
in  which  the  life  of  these  delirious  subjects  is  passed.  Sometimes 
they  meet  with  sympathy  in  the  popular  mind,  as  happened  in  the 
case  of  Davide  Lazzaretti,  to  mention  one  recent  case  ; but  for  the 
most  part  they  encounter  derision,  hostility,  and  opposition,  that 
furnish  elements  to  the  delirium  of  persecution.  The  following 
clinical  report  is  of  more  value  than  any  description  : 

Observation  XX. — Carlo  Is.  di  Luigi,  of  Rome,  bachelor,  student  of 
literature  and  philosophy,  was  admitted  into  the  asylum  of  Naples  for  the 
first  time  on  September  17,  1898,  when  he  was  aged  twenty-four.  He 
had  been  suffering  from  hallucinations  of  hostile  content,  and  he  declared 
himself  to  be  a victim  of  suggestion  made  from  a distance,  although  he 
did  not  well  know  who  was  the  author.  He  added,  further,  that  certain  of 
his  friends,  at  a dinner  that  had  been  given  him  a few  days  before,  had 
put  a large  quantity  of  bromide  into  the  wine. 

We  have  been  able  to  find  out  hardly  anything  of  his  family  history. 
From  his  own  personal  narration  the  following  has  been  ascertained : He 
has  always  been  of  delicate  health,  a keen  student,  but  easily  exhausted  ; 
he  had  a high  opinion  of  his  abilities,  and  in  the  depths  of  his  mind  was 
really  proud,  but  he  cleverly  dissimulated  the  exaggerated  idea  he  had 
of  his  own  importance.  He  was  affectionate  towards  his  parents,  attached 
to  his  home,  avoided  companions,  whether  good  or  bad,  and  was  fond  of 
solitude.  Why  he  avoided  companions  he  is  quite  ready  to  confess  to-day, 
now  that  his  delirium  of  grandeur  is  fully  developed  : he  considered  them 
of  srnall  value  in  comparison  with  himself,  and  he  was  afraid  that  they  were 
hostile  to  his  grandiose  projects. 

From  these  details  of  his  previous  history  and  from  what  we  have 
subsequently  learned  from  him,  it  is  clear  that  originally  he  was  proud, 
vain,  and  given  to  dreaming.  The  delirium  of  persecution  arose  second- 
arily, and  was  nourished  by  the  presentiment  he  had  that  those  about  him 
would  be  hostile  to  his  designs,  and  also  by  the  subsequent  acoustic, 
optic,  and  gustatory  hallucinations. 


602 


PSYCHIATRY 


During  this  first  period  of  his  life  in  the  asylum,  lasting  less  than  two 
months,  the  ideas  of  grandeur  that  occupied  his  mind  could  only  be 
inferred  from  his  attitude,  from  some  faulty  phrase,  or  from  some  word 
that  escaped  him  unawares.  He  was  still  very  prudent,  and  had  sufficient 
judgment  left  to  understand  that  the  proclamation  of  these  ideas  would 
prolong  his  confinement  in  the  asylum.  He  would  not  commit  himself 
by  speaking  of  anything  beyond  the  persecution  that  he  had  suffered, 
in  proof  of  which  he  could  bring  forward  evidence,  the  principal  argument 
being  that  he  had  been  arrested  by  the  police  and  taken  to  the  asylum. 

The  following  letter  is  one  in  which  he  asked  for  his  discharge.  We 
reproduce  it  in  order  that  it  may  serve  also  for  comparison  with  what  he 
wrote  during  the  second  period  of  his  life  in  the  asylum,  the  style  of  the 
latter  compositions  being  completely  altered  : 

‘ Excellent  Sir, 

‘ Of  myself,  and  supported  by  the  judgment  of  several  medical  men, 

I can  assure  you  that  I am  far  from  being  affected  by  delirium  of  persecu- 
tion or  by  any  other  form  of  insanity  ; but  that,  as  the  result  of  real 
persecution,  which  I now  dismiss  from  my  mind,  I have  been  reduced  to 
such  a condition  that  it  has  become  much  easier  to  make  me  the  victim 
of  suggestion  than  would  have  been  possible  under  other  circumstances. 

‘ Again,  to  any  person  who  may  object  that  for  that  very  reason  it  is 
necessary  I should  remain  in  the  asylum,  I would  reply  that,  owing  to 
my  habits  and  to  my  psychic  nature  itself,  it  is  much  more  probable  that 
if  I am  not  sent  to  my  own  home  as  soon  as  possible,  seeing  that  I cannot 
sleep  here,  cannot  accustom  myself  to  my  surroundings,  and  am  deprived  ’ 
of  the  conversation  and  the  sight  of  my  parents  and  friends — it  is  much  ; 
more  probable,  I say,  that  my  mental  organism  will  degenerate  under  this  ; 
enforced  imprisonment  more  readily  than  it  would  within  the  walls  of  j 
my  own  home. 

" You  may  deal  with  this  letter  as  you  think  best ; I merely  wish  to  ? 
warn  you.  ' 

‘ Accept  my  respects,  which  I have  pleasure  in  tendering  you. 

‘ Your  most  devoted, 

‘ Carlo  Is.’ 

Note  should  be  taken  of  the  phrase  ‘ I wish  to  warn  you,’  by  which  ' 
he  intended  to  warn  the  superintendent  of  the  asylum  to  be  careful  not  ^ 
to  abuse  a man  of  such  importance  as  he.  5 

He  left  the  asylum  greatly  improved  on  November  7,  1898,  but  re-‘  ; 
turned  on  February  17,  1901,  after  having  caused  a great  disturbance  at  | 
the  University,  where  he  used  daily  to  insult  Professors  and  students,  | 
interrupting  the  lectures  and  claiming  that  he  should  be  allowed  to  take 
the  place  of  the  Professor  and  teach  the  young  men  the  true  science, 
the  doctrine  revealed  hy  God  to  Carlo  Is.  of  Rome. 

In  a journal  for  May,  1901,  his  morbid  personality  is  thus  delineated  : 

The  most  notable  mental  disturbances  of  this  patient  are  in  the  purely 
intellectual  field.  He  has  a very  pronounced  delirium  of  grandeur,  with 
vast  ramifications,  thoroughly  organized,  reinforced,  and  increased  by  the 
continual  flux  of  anomalous  products.  This  is  the  fulcrum  of  his  diseased 
personality.  He  is  the  greatest  genius  on  earth,  the  Elect  of  God,  the 
Anointed  of  God,  the'  Redeemer  of  Humanity,  the  one  who  is  to  bring 
perpetual  peace  on  earth  for  the  happiness  of  mankind. 

It  is  only  a short  time  since  he  came  fully  to  understand  himself,  for 
God,  before  revealing  Himself  to  him,  wished  to  try  him  by  long  and  severe 
affliction.  The  school  of  su-ffering — that  suffering  which,  as  a young  man,' 
he  learned  to  love  in  the  lachrymose  pages  of  Giacomo  Leopardi,  was  the 


PARANOIA 


603 


first  preparation  required  for  the  revelation  of  the  Divinity.  His  acute 
mind  and  his  hypersensitive  spirit  always  caused  him  to  feel  keenly  the 
vulgarity  and  baseness  of  those  in  whose  midst  he  was  often  condemned 
to  live.  At  the  age  of  sixteen,  when  a student  in  the  Lyceum,  he  felt  a 
great  and  tormenting  ambition  to  become  a conqueror  in  arms  and  a 
ruler  of  nations.  But  what  a contrast  between  the  external  world  and 
the  world  of  his  thoughts  ! To  attain  his  destiny,  he  would  have  required 
a race  of  heroes,  and  in  reality  he  saw  himself  surrounded  by  companions 
who  were  pusillanimous,  ignorant,  incapable  of  understanding  him,  and 
who  often  mocked  him.  He  felt  that  he  was  alone  in  the  world — alone 
with  his  dreams  and  his  winged  hopes. 

He  was,  however,  tranquil  in  his  solitude,  and  would  have  awaited  the 
ripening  influence  of  time  with  all  due  calm,  if  shortly  afterwards  an  irre- 
sistible and  unheard-of  persecution  had  not  been  commenced  against  him. 
L^nknown  persons  would  sometimes  meet  him  and  make  faces  at  him  ; at 
other  times  they  would  come  under  his  windows  at  night  and  wait  for  him 
to  show  himself,  so  that  they  might  insult  him ; or,  again,  they  acted  upon 
him  from  a distance  by  means  of  electricity  and  magnetism.  This  persecu- 
tion continued  without  interruption  for  two  years.  Although  a profound 
scrutator  of  natural  phenomena,  as  he  likes  to  call  himself,  he  could  not 
understand  what  was  happening  in  and  around  him  ; and  as  he  had  never 
done  harm  to  anyone,  he  was  unable  to  discover  any  reason  for  this  collec- 
tive conspiracy  against  his  peace,  his  studies,  and  his  very  existence.  He 
could  not  admit  the  intervention  of  supernatural  causes,  because  he  did 
not  believe  in  the  supernatural.  He  was  an  atheist,  and  his  atheism 
arose  from  the  fact  that  he  could  not  conceive  of  a Deity,  an  intelligent 
agent,  outside  of  Nature.  However,  as  his  studies  in  metaphysics 
gradually  advanced,  his  idea  of  the  Divinity  gradually  became  more  and 
more  detached  from  the  anthropomorphic  personification  presented  by 
the  various  religions,  and  with  him  it  became  more  and  more  completely 
identified  with  Nature,  until  this  formula,  which  is  to-day  the  first  dogma 
of  his  catechism,  burst  forth  from  him,  ‘ God  and  Nature  are  identical.’ 

If  God  and  Nature  are  identical,  if  God  is  present  in  all  natural 
phenomena,  and  if  those  phenomena  are  God  Himself,  then  he  could  not 
admit  that  the  persecution  of  which  he  was  a victim  could  be  carried  on 
without  the  knowledge  of  God,  and  much  less,  therefore,  against  the  will  of 
God. 

Accordingly,  the  persecution  of  Carlo  Is.,  being  a natural  phenomenon, 
was  by  God  Himself,  or,  as  we  may  say  for  convenience  of  expression,  it 
was  brought  about  by  Divine  suggestion. 

When  he  had  come  to  understand  this  supreme  truth,  which  came 
to  him,  as  he  says,  through  his  sufferings,  he  at  once  deduced  from  it 
the  corollary  that  God  wished  to  punish  him  for  the  illusion  of  atheism  in 
which  he  had  lived,  and  if  God  had  not  allowed  him  to  perish  like  so  many 
other  mortals  who  lived  constantly  in  a state  of  delinquency  or  folly,  that  was 
as  much  as  to  say  that  our  subject  was  a privileged  man,  one  of  the  elect  of 
God.  When  his  thoughts  had  taken  this  direction,  the  persecution 
terminated  ; then  a second  period  of  hallucinations  commenced.  This 
he  calls  the  period  of  ‘ Divine  Revelation,’  but  it  might  better  be  termed 
the  period  of  ‘ Annunciation.’  Conversations  commenced,  when  he  was 
awake  or  half  awake,  with  blessed  spirits,  with  the  souls  of  the  great  de- 
parted who  had  best  invoked  the  Divinity,  when  on  earth.  These  spirits 
appeared  to  him  and  spoke  to  him,  although  sometimes  he  heard  their 
words  without  seeing  them.  He  does  not  repeat  the  speeches  that  they 
addressed  to  him,  but  he  points  out  that  the  mere  fact  of  the  apparition 
of  beings  so  near  to  God  signified  that  God  was  coming  near  to  him,  and 
that  God  was  initiating  in  Carlo  Is.  a process  of  deification,  a course  that 
would  render  him  Divine.  After  the  blessed  spirits  came  the  saints.  He 


604- 


psychiatry 


remembers,  among  other  incidents,  that  one  night  he  was  assisted  by  Sar 
Gennaro,  who  called  St.  Peter  and  St.  Paul  to  his  bedside,  along  with 
some  other  saints  whom  he  does  not  remember.  After  the  saints  there 
came  a winged  messenger,  the  angel  Ariel,  as  an  intermediary  betweer 
God  and  himself.  At  that  time  he  began  to  write  a book  about  the 
hierarchies,  in  which  he  meant  to  treat  of  saints,  angels,  seraphim,  anc 
cherubim.  At  this  point  his  maturity  was  complete,  the  extreme  limil 
of  his  perfectibility  was  reached,  and  accordingly  the  great  annunciation 
was  made.  The  sound  of  a trumpet  was  heard,  and  above  it  he  coulc 
discern  clearly  the  words,  ‘ Thou,  Carlo  Is.  of  Rome,  art  anointed  oi 
God.’ 

From  that  day  he  has  spoken  only  the  word  of  God,  and  he  writes 
only  to  Divine  dictation.  All  his  actions  are  inspired  by  God,  are 
God  Himself,  even  the  Divinity  rendered  tangible.  His  mission,  as  the 
Anointed  One,  the  Messiah,  is  to  redeem  the  human  race  from  the  state\ 
of  delinquency,  folly,  and  anarchy  in  which  it  now  is,  and  to  bring  about' 


<1 

<\ 


I 

Fig.  8o. — Carlo  Is.  of  Rome,  Religious  Paranoiac.  | 

perpetual  peace,  the  conditions  of  which  he  has  codified  in  a species  of^ 
constitution  containing  seventy  articles.  The  first  necessity  for  the 
attainment  of  perpetual  peace  is  that  he.  Carlo  Is.  of  Rome,  should 
ascend  the  throne  of  Italy,  and  that  Victor  Emmanuel  should  leave  it, 
either  by  voluntary  abdication  or  as  the  result  of  a popular  revolution. 
God  will  take  care  to  ‘ suggest  ’ abdication  to  the  King  or  revolution  to 
the  populace.  Under  the  reign  of  peace,  the  new  social  system  will  be 
based  on  the  following  fundamental  politico-economical  principles  : 

Abolition  of  private  property,  which  would  devolve  to  the  State,  the 
State  providing  for  the  necessities  of  each  individual. 

Absolute  equality  between  man  and  woman. 

Matrimony  to  be  tolerated,  although  it  represents  a form  of  slavery. 

Moral  and  social  rehabilitation  of  the  important  and  beneficent 
institution  of  prostitution. 

Abolition  of  the  hereditary  monarchy,  and  popular  election  to  all  | 
public  offices,  from  town  councillors  to  the  heads  of  the  national  policy. 


PARANOIA 


605 


It  would  be  sufficient  to  apply  this  regime  in  Italy,  and  all  other  nations 
would  feel  the  necessity  of  imitating  it.  The  boundaries  between  States 
would  next  be  abolished ; the  whole  world  would  become  one  single  State, 
and  Carlo  Is.  of  Rome  would  have  the  undisputed  sovereignty  of  it. 

Such  is  the  genesis  and  the  structure  of  his  delirium,  which  completely 
transforms  his  personality  and  enslaves  his  whole  patrimony  of  culture. 
Everything  that  will  not  serve  to  augment  his  own  morbid  personality  is 
denied  by  him.  All  the  sciences  are  false— they  are  simply  pretentions 
to  science.  History  is  unworthy  of  credence,  because  everything  is  douhtf^ll 
as  regards  the  past  ; literature  alone  has  some  importance  in  the  formation 
of  the  sentiments. 

With  regard  to  the  theme  of  the  worthlessness  of  all  the  sciences,  he 
has  written  very  largely  in  the  asylum.  His  clinical  record  is  interspersed 
with  many  of  his  productions  in  writing.  I quote  the  following  examples  : 

‘ In  psychology  scientific  observation  is  impossible 
‘ we  distinguish  the  observation  That  the  psychologist  makes  upon 
himself  from  the  observation  that  the  psychologist  makes  or  ought  to 
make  on  other  anthropic  individuals. 

‘ The  former  is  termed,  in  a conventional  way,  “ introspection.” 

‘ it  is  clear  that  introspection  is  easier  for  those  psychologists  who  are 
self-observers. 

‘ observation  of  others  always  presents  greater  difficulties,  even  putting 
aside  the  cases  of  observation  of  those  not  present,  the  psychology  of 
illustrious  men,  etc. 

‘ to  state  why  psychic  observation,  conducted  with  that  rigour  de- 
manded by  science,  is  an  impossibility,  is  to  state  in  great  measure  why 
science  itself  is  impossible. 

‘ although  a single  reason  may  be  sufficient,  viz.,  the  image-creating 
value  of  a human  word,  it  will  be  advantageous  to  adduce,  not  an  initial 
series  of  the  inhnite  series  of  reasons,  but  a few  other  essential  reasons  that 
will  corroborate  the  allotropic  state  of  the  psyche  of  the  reader  who 
is  practised  in  those  studies  called  scientific  and  has  been  deceived  by  the 
presumed  sciences. 

‘ to  eviscerate  the  subject  of  the  entity  of  the  human  word  is  to 
devastate  and  ruin  the  scientific  field  hitherto  cultivated  in  the  human 
monad  by  false  views  which  are,  however,  rendered  alluring  by  the 
very  powerful  witchcraft  of  illusions. 

‘ in  fact,  hypotheses  often  become  theses,  and  when  they  have  become 
theses  they  often  become  hypotheses  over  again 

' these  farces  are  due  to  the  varying  powers  of  reasoning  of  the  different 
writers 

‘ since  a great  reasoner,  of  homogeneous  culture,  can  always  confute 
a minor  reasoner,  and  that  in  psychology  and  in  every  other  study.  . . . 

‘ and  I affirm  that,  as  psychology  is  an  absolute  requirement  of  science, 
so  is  it  with  psychiatry 

‘ the  normal  psyche  is  not  to  be  scrutinised  by  science,  and  therefore 
the  diseased  psyche  is  also  inscrutable  to  the  inquiries  of  science 

‘ the  psychologist  knows  nothing  whatever  of  psychology  and  the 
psychiatrist  nothing  whatever  of  psychiatry.  . . . 

‘ amid  the  contemporary  illusions  of  science,  either  of  the  mathema 
that  is  not  mathematical  or  of  the  scientific  nature  of  science,  it  is  clear 
that  some  psychiatrists  may  fall  unconsciously  into  the  error  of  declaring 
insane  a person  who  is  not  insane 

‘ that  is  hurtful  to  the  individual  as  far  as  regards  the  contemporary 
social  organization 


6o6 


PSYCHIATRY 


‘ what  is  the  nature  and  extent  of  the  crime  of  such  a declaration,  made 
perhaps  consciously,  but  under  an  illusion,  and  therefore  unconsciously, 
in  this  daily  presumption  of  being  scientific  ; and  whether  it  be  a crime 
or  not,  whether  it  be  or  be  not  to  such  and  such  a degree  in  accordance 
with  the  will  of  Gpd,  is  not  declared  ; but  it  is  certainly  regarded  as  a 
criminal  offence  that  the  only  man  of  God,  Carlo  Is.  of  Rome,  should  be 
able,  by  the  will  of  God,'  to  express  the  judgment  of  God;  who  does  not 
impugn,  either  by  himself  or  by  His  elect,  the  integrity  of  the  psychiatrists, 
to  whom  it  is  already  painful  enough  to  fall  below  the  scientific  character  | 
of  their  teachings^  ...  ! 

‘ what  applies  to  the  individual  applies  to  the  State  . . . 

‘ in  the  social  equilibrium  which  will  be  established  by  my  peace, 
contemporary  science  will  constitute  the  historic  content  of  culture,  it 
being  necessary  to  collect  it,  to  weigh  its  worth,  and  to  reduce  it  to  ’its  i 
minimum  after  the  return  to  God,  and  after  receiving  the  direct  revelation 
from  God,  the  order  of  composition  being  according  to  one  of  the  notes 
of  my  peace,  in  my  fashion  . 

‘ it  is  asked  whether  he  who  liberates  the  human  race  from  the  torture 
of  mental  slavery  and  from  the  evils  that  follow  upon  it,  allowing  the  con- 
ditions for  the  purest  blossoming  of  the  mind  to  come  into  force,  be  or  be 
not  the  Saviour  ; and  it  is  hoped  that  into  him  will  not  be  driven  the 
supposed  nail  from  the  supposed  cross  of  the  supposed  Christ. 

‘ I shall  continue  to-morrow  to  write  about  the  circumstances  that 
prove  me  to  be  the  Saviour  of  the  human  race  and— I shall  not  say  as  a • 
consequence,  but  by  precedence — the  Christ  of  God,  and  therefore  neces- 
sarily the  Sovereign  Arbiter  of  the  human  race.’  ! 

As  will  be  seen,  he  speaks  of  a supposed  Christ.  It  is  important  to  ! 
note  how  he  judges  of  the  historical  personality  of  the  Nazarene.  In  his 
view  Jesus  never  existed  at  all,  either  as  ih^n  or  as  the  Son  of  God.  He  ' 
was  simply  a phenomenon — Jesus.  The  apostles,  the  disciples,  and  ! 
people  of  Judea  and  of  Galilee,  acting  under  the  suggestion  of  God, 
believed  that  they  saw  and  heard  Jesus,  but  in  reality  they  neither  saw  ^ 
nor  heard  anything  at  all.  It  was  simply  a matter  of  Optic  and  acoustic  • 
hallucinations.  The  Word  was  not  made  flesh,  and  God  did  not  become  i 
man  in  J esus  Christ ; but  He  produced  these  phenomena  in  order  to  teach  j 
a new  morality  to  the  world.  The  first  personality  really  assumed  by  God  1 
is  Carlo  Is.  ; and  God  has  promised'  that  after  him  there  will  never  be  l 
another  Messiah  on  earth.  j 

He  cannot,  however,  fulfil  his  mission  as  Messiah  within  the  walls  of  ^ 
the  asylum,  and  therefore  he  daily  protests  against  his  confinement,  ^ 
and  sends  out  his  orders  in  the  name  of  God  : 

‘ it  being  understood  that  men  have  to  be  men  and  not  slaves  ; and  it 
being  once  more  declared  that  Carlo  Is.  of-  Rome  has  not  the  power  of 
thought-reading 

‘ that  being,  as  they  would  understand  it,  a vice 
‘ and  the  said  Carlo  Is.  of  Rome,  having  been  detained  in  an  asylum 
from  the  17th  day  of  February,  1901,  as  insane 
‘ whilst  he  is  the  only  man  truly  rational 
‘ being  the  anointed  of  God 

‘ and  Carlo  Is.  of  Rome  having  been  verbally  declared  insane  by 
ignorant  people  on  4th  May 

‘ and  it  being  added  that  Carlo  Is.  of  Rome 

‘ should  remain  in  the  asylum  until  the  time  of  his  supposed  cure 
which  would  be  the  greatest  folly 
‘ delinquency  or  anarchy 


PARANOIA  607 

‘ and  the  scientific  character  of  psychiatry  having  been  already 
declared  to  be  null 

‘ God  commands  through  Carlo  Is.  of  Rome 

‘ that  Carlo  Is.  of  Rome  be  immediately  restored  to  liberty  as  the 
assumed  of  God,  and  heir  to  the  throne 

‘ and  that  he  be  liberated  on  the  4th  May,  1901,  the  throne  being- 
ascended  on  19th  May,  1901 

‘ If  not,  in  the  universal  madness, 

‘ the  whole  of  Italy  shall  be  a sea. 

‘ Naples,  4th  May,  1901.’ 

At  present  the  perceptive  process  is  disturbed  by  hallucinations  and 
illusions.  He  hears  the  voice  of  God  which  dictates  to  him  ; he  measures, 
the  velocity  of  God  by  meteoric  phenomena  ; he  predicts  storms,  cata- 
clysms, etc.  He  has  a ready  and  retentive  memory.  He  remembers, 
to  the  smallest  details  facts  affecting  his  own  personality,  even  when  he 
tries  to  go  back  to  his  infancy.  His  attention  is  always  alert. 

As  to  his  sentiments,  it  is  important  to  note  that  he  never  received  any 
religious  training  in  his  family.  His  maternal  grandfather  was  per- 
secuted and  martyred  by  the  Pontifical  police,  and  his  mother,  who  never 
goes  to  Mass,  told  him  the  story  of  those  persecutions,  and  filled  him  with 
scorn  of  everything  that  had  anything  to  do  with  ecclesiasticism.  From 
men  to  the  principles  that  they  represent  is  a short  step,  and  the  transi- 
tion from  anti-clericalism  to  atheism'  is  easy. 

He  is  affectionate  and  respectful  towards  his  parents,  and  he  would, 
feel  it  his  duty  to  assist  them  should  they  require  his  assistance.  Occa- 
sionally he  has  suspected  that  he  might  be  of  some  other  origin,  but,  as  he 
lately  learned  from  God  that  he  is  descended  from  an  Etruscan  Lucumone, 
and  as  his  mother’s  family  was  originally  Tuscan,  he  has  no  longer  any 
doubt  that  his  parents  are  really  those  whose  names  appear  as  such  in 
the  register. 

He  has  never  experienced  love  for  a woman  in  any  of  its  aspects.  Up 
to  his  present  age  he  has  never  felt  sexual  impulses.  It  may  happen 
that,  after  the  peace  has  been  realized,  God  will  allow  him  to  have  a wife. 

In  the  asylum  he  behaves  quietly. 

Paranoia  Erotica. — This  must  be  understood  as  merely  an  insuffi-. 
dent  and  abnormal  psycho-somatic  development.  Considered  in 
its  harmonious  and  complex  structure,  it  occurs  often  in  individuals, 
of  defective  sexual  life,  not  much  inclined  to  copulation.  Some- 
times the  subjects  are  old, maids  who  have  never  had  an  opportunity 
of  marrying,  and  never  even  possessed  any  of  those  unconscious 
qualities  of  attraction  that  arise  from  harmony  of  spirit  in  one 
whose  normal  instincts,  tempered  by  education,  are  summed  up 
in  charm  of  look  and  conduct.  They  are  eccentrics,  dreamers, 
idealists,  indifferent  to  passion,  and  pass  their  youth  chasing  the 
ignis  fatuus  of  fancy.  In  most  cases  sexual  desire  is  absent,  and 
never  do  they  find  among  their  acquaintances  the  man  upon  whom 
they  can  exercise  the  fascination  of  love  and  the  desire  that  lead 
two  souls  to  unite.  They  read,  romances  and  expend  their  powers 
in  the  realm  of  chimeras,  and  the  more  these  participate  in  the 
structure  of  their  minds  the  more  they  are  removed  from  reality, 
and  the  more  fully  do  they  lose  possession  of  those  intellectual  or 
instinctive  resources  (supposing  they  once  had  them,  even  in  a. 


6o8 


PSYCHIATRY 


slight  degree),  by  virtue  of  which  the  normal  woman  succeeds  in 
realizing  some  of  her  objects.  As  a rule,  they  give  themselves  up 
to  an  ascetic  life. 

In  other  cases,  although  more  rarely,  the  sexual  desire  exists 
and  torments  the  subject ; but  domestic  circumstances,  education, 
timidity,  or  ugliness  conspire  against  the  poor  woman,  on  whom 
no  one  ever  casts  a glance  of  love.  Sometimes  they  are  widows 
whose  sexual  relations  have  been  very  limited  and  unhappy.  They 
lost  their  husbands  very  early,  and  Love  never  smiled  on  them 
again. 

All  of  them  have  nourished  a dream,  a vague,  indefinite  aspira- 
tion for  a long  time.  They  have  never  known  the  man  of  their 
hearts,  or  he  has  been  merely  a fleeting  apparition.  Their  dreams 
and  aspirations  have  remained  concealed  amidst  the  turmoils  of 
this  life,  which  continues  inexorably  on  its  parabolic  course.  Adap- 
tation to  new  circumstances  chokes  off  those  ideals  that  have  not 
been  realized.  Youth  is  spent,  for  the  most  part,  in  sadness  and 
solitude,  the  decline  of  life  draws  on  apace,  and  the  helpless  mind 
is  afflicted  with  profound  sorrow.  Just  as  the  sailor,  when  he  is 
driven  farther  and  farther  from  the  land,  clings  to  a last  illusion 
that  he  will  be  able  to  set  foot  on  shore  again,  so  the  timid 
dreamer  of  the  dreams  of  love  illudes  herself  that  she  will  finally 
attain  to  her  supreme  joy,  the  love  so  long  sighed  for.  He  will 
be  a handsome  youth,  a personage  of  importance  in  politics  or  in 
science,  some  prominent  personality.  Then  commence  the  declara- 
tions, the  letters,  and  the  persistent,  annoying,  and  protracted  visits. 
Nothing  will  restrain  these  subjects.  They  claim  that  they  have 
the  right  to  love,  and  to  be  loved  in  return.  He  who  replies  to 
one  of  their  letters  is  lost,  for  documentary  evidence  is  there,  and 
the  broadest  illusory  interpretation  is  given  to  the  coldest  and  most 
measured  communication. 

They  declare  that  they  love,  that  they  have  the  right  to  mani- 
fest that  sentiment,  and  to  be  loved  in  return.  They  maintain  this 
right  of  theirs  with  a wealth  of  argument.  A lady  who  had  been 
a widow  from  her  youth,  neuropathic,  and  with  many  psycho- 
somatic degenerative  stigmata,  said  to  a married  friend  of  mine  : 

‘ I know  that  you  are  married,  but  as  I love  you,  and  have  your 
assurance  that  you  love  me,  I know  that  I am  not  wronging  your 
wife  in  any  way.  Even  supposing  she  should  become  aware  of  our 
relations,  she  will  understand  that  this  is  simply  a noble  aflinity 
of  sentiments  between  you  and  me,  and  slie  will  have  no  reason 
to  object  to  it.  Understand  this  : I must  love  you,  see  you,  and 
hear  you  utter  an  expression  of  love.  You  love  me  very  much  ; I 
know  it,  and  have  no  doubt  of  it.’  This  poor  man  had  to  suffer 
the  torture  of  protracted  visits  and  of  stereotyped  speeches, 
whilst  the  lady  threatened  to  commit  suicide  if  he  refused 
her  the  indispensable  comfort.  She  believed  she  had  the  right  to 


PARANOIA 


609 


love  that  man,  and  the  right  to  his  love  in  return.  She  had  the 
conviction  that  he  loved  her,  and  could  see  no  reason  why  he  ought  not 
to  love  her.  She  thought  that  she  was  not  giving  any  cause  for  offence 
to  the  wife  of  X.,  and  she  made  it  plain  that  she  considered  herself 
to  have  a preferential  right  over  his  wife.  She  did  not  understand 
the  delicate  position  in  which  she  put  Mr.  X.  with  respect  to  his 
own  family  and  his  wife’s  relatives.  There  was  no  question  of 
sexual  relations. 

In  this  case  there  was  no  sign  of  illusions  or  of  hallucinations, 
for  this  form  of  paranoia  is  developed  exclusively  in  the  intellectual 
field.  Notwithstanding  the  severely  correct  behaviour  of  Mr.  X., 
no  idea  of  persecution  appeared  for  many  years  to  modify  this 
clinical  picture. 

In  another  category  of  cases,  the  erotic  delirium  is  followed  by 
the  delirium  of  persecution.  Here  is  a short  example  selected 
from  my  observations  in  my  private  clinique  : A young  woman  of 
about  thirty-five,  after  waiting  long  for  a husband  of  some  sort,  began 
to  become  pensive  and  gloomy  in  disposition.  She  neglected  her 
domestic  duties,  frequently  shut  herself  up  in  her  own  room,  and 
sometimes  behaved  towards  the  rest  of  the  family  in  a strange  and 
unusually  high-handed  manner.  She  dressed  in  an  exaggerated  and 
original  style.  One  day  she  was  detected  in  the  act  of  posting  a 
letter  to  Mr.  X.,  a young  man  belonging  to  the  district,  who  had  been 
away  from  it  for  some  time,  and  who  had  formerly  visited  her  house. 
The  letter  was  full  of  ardent  phrases,  as  though  the  two  had  been 
lovers.  When  questioned,  she  declared  that  she  had  proof  that 
he  loved  her  and  wished  to  marry  her ; that  she  had  learned  it  from 
his  words  and  from  signs  ; that  he  had  appeared  to  her  in  a dream, 
and  she  must  of  necessity  marry  him.  The  clearest  proof  that  he  had 
never  thought  of  contracting  matrimony  or  even  of  giving  her  any 
indication  of  such  an  intention  was  laid  before  her,  but  all  to  no 
purpose.  She  had  a conviction  to  the  contrary,  although  abso- 
lutely without  grounds,  and  when  she  found  that  the  members,  of 
her  family  quite  properly  opposed  her  intention  she  developed'  a 
florid  delirium  of  prosecution,  taking  up  an  attitude  of  hostility 
and  violence.  The  family  made  a last  attempt  to  remedy  matters 
by  inviting  Mr.  X.,  who  was  a far-off  relation,  to  come  and  stay 
with  them,  and  try  to  persuade  the  young  woman  that  her  ideas 
had  no  real  foundation.  Mr.  X.  came,  and  made  her  the  most 
explicit  declaration  that  it  was  quite  impossible  for  him  to  enter 
into  matrimony.  He  proved  to  her  that  she  had  made  a mistake, 
and  that  it  was  a dream,  and  nothing  else.  Notwithstanding  all 
this,  her  two  deliria  remained  unaltered.  She  must  marry  Mr.  X., 
who  loves  her  and  desires  her  to  be  his  wife,  and  it  is  the  members 
of  her  own  family  who  hinder  her  from  doing  so. 

In  another  class  of  cases,  which  are  much  rarer,  there  is  a 
delirium  of  erotic  persecution  from  contrast  of  thoughts  or  tendencies. 

39 


6io 


PSYCHIATRY 


The  subjects  are  usually  old  maids  and  lascivious  men,  who 
always  present  some  anomalous  features  and  grave  hereditary 
neuropathic  taint.  Their  delirium  takes  the  form  of  a belief  that 
they  have  suffered,  or  are  threatened  with,  carnal  violence.  Such 
delirium  is  the  result  of  dreams  or  of  true  hallucinations  or  illusory 
interpretations  of  anomalies  of  the  kinsesthesis  in  the  sexual  sphere. 
In  all  these  cases  we  have  to  deal  with  individuals  whose  mental 
life  is  centred  in  erotic  images  and  ideas.  The  priest  Potenza 
killed  his  old  landlady,  who  had  always  refused  his  advances, 
because  he  was  convinced  that  she  had  had  him  constuprated  by 
her  dog  whilst  he  was  asleep,  with  the  object  of  doing  him  the 
greatest  possible  injury.  A woman  who  was  in  the  asylum  for 
many  years  was  always  to  be  seen  leaning  against  the  wall  with 
her  left  hand  over  the  region  of  the  anus,  for  fear  she  should  be 
abused  pederastically  (conviction  or  hallucinations). 

I A distinguished  lady,  over  thirty  years  old,  of  robust  health, 
and  highly  cultured,  conceived  the  delirious  idea  that  she  had 
been  the  victim  of  incest  on  the  part  of  her  brother.  She  had  seen 
him  one  night  on  her  bed,  and  had  been  conscious  of  sexual  sensa- 
tions. She  had  no  doubt  at  all  that  her  brother  had  had  inter- 
course with  her,  although  he  was  really  abroad  at  the  time.  When 
she  came  to  Naples  to  consult  me  she  expressed  her  conviction  that 
her  brother  was  in  Naples,  and  desirous  of  continuing  to  vent  his 
sexual  instincts  upon  her.  It  was  impossible  to  persuade  her  to 
the  contrary.  This  lady  came  from  a district  where  incest  is  very 
common. 

We  distinguish,  therefore  : 

1.  An  erotic  paranoic  character  (erotic  paranoidism). 

2.  Simple  erotic  paranoia. 

3.  Erotic  paranoia  with  delirium  of  persecution. 

4.  Erotic  paranoia  through  contrast. 

The  following  summary  of  a case  is  characteristic,  and  ma}^  be 
compared  with  the  progressive  chronic  delirium  of  persecution  : 

Observation  XXL — Or.  Bart.,  fu  Francesco,  fifty-one  years  of  age, 
native  of  Fossano,  in  Piedmont,  but  resident  in  Naples  for  many  years  as 
an  employe  on  the  Crown-lands,  was  admitted  into  the  asylum  of  Naples 
on  November  7,  1902.  The  circumstance  that  induced  the  police  to  take 
such  measures  with  him  was  the  fact  that  he  had  sent  a series  of  love- 
letters  to  a young  lady  belonging  to  high  society  in  Naples,  with  whom 
he  was  and  is  still  enamoured,  and  whom  he  believed  and  still  believes  to 
return  his  feelings. 

According  to  the  assertions  of  our  patient,  there  had  been  no  neuro- 
pathic subjects  amongst  his  antecedents.  We  are  aware,  however,  that 
his  father  died  very  young.  He  himself  presents  certain  anthropological 
signs  of  degeneration  of  some  importance  — occipital  plagiocephaly, 
cranium  flattened  behind  ; slight  hypsicephaly  ; lop-ears,  especially  the 
right  one ; genitals  very  little  developed  ; penis  infantile  ; left  testicle  of 
the  size  of  a large  pea. 


PARANOIA 


6ii 


He  himself  tells  us  that  the  story  of  his  sexual  life  is  very  poor.  He 
has  not  approached  women  more  than  four  or  hve  times,  owing  to  fear 
of  contagion  and  because  he  wished  to  take  care  of  his  health,  so  that  he 
might  live  a hundred  years.  The  truth  is  that  he  has  never  felt  very 
strong  carnal  stimuli  ; on  the  other  hand,  he  has  constantly  fallen  in  love 
with  ladies  superior  to  himself  in  social  and  economic  position. 

His  love  episodes  have  always  been  of  a platonic  character,  and  are  to 
be  counted  by  the  dozen.  He  is  now  fifty-one,  and  as  he  remembers  these 
incidents,  he  is  astonished  that  none  of  them  ever  ended  in  matrimony. 
For  a while  he  believed  that  God  was  making  sport  of  him,  causing  him  to 
fall  in  love  time  after  time,  and  denying  him  all  possibility  of  contracting 
matrimony  in  any  case  ; but  maturer  and  more  recent  reflections  have 
led  him  to  a different  conclusion — namely,  that  his  previous  adventures 
in  love  were  nothing  more  than  a necessary  preparation  for  the  present 
case.  This  is  the  strongest,  the  only  really  strong  passion,  he  has  had, 
and  if  it  has  not  a successful  issue  he  feels  that  he  cannot  survive  it. 

‘ Marry  or  die  ' is  his  motto  to-day. 

In  proof  of  this,  I reproduce  here  a portion  of  a letter  that  he  addressed 
some  time  ago  to  the  lady  in  question  : 

‘ I have  said  that  I have  always  been  rather  indifferent  to  matrimony 
because  I thought  only  of  my  health,  and  my  principal  object  in  life 
was,  and  is,  to  indulge  in  few  or  no  enjoyments  and  to  live  a hundred  years, 
with  the  aid  of  special  study  and  a special  system  of  hygiene  which  I 
have  myself  devised.  As  for  the  rest,  it  seems  to  me  that  I have  not  been 
master  of  my  will,  but  simply  one  of  God’s  toys,  a new  plaything  with 
which  God  amuses  Himself,  causing  me  to  fall  in  love  so  many  times, 
while  I have  never  once  managed  to  arrange  a marriage.  It  seems  as 
though  God  intended  to  say  to  me  every  time  I fell  in  love  : “ Yes,  yes, 
thou  art  in  love,  but  thou  lovest  not  yet  enough.  . . . Wait,  wait  until 
I send  thee  another  angel,  much  more  handsome  and  much  more  wonderful 
than  any  of  the  previous  ones,  and  then  thou  wilt  see  how  much  thou  wilt 
love,  thou  wilt  see  that  thou  wilt  truly  love.”  And  now,  behold,  after 
having  been  so  often  in  love,  both  in  the  past  and  within  recent  times, 
hardly  did  you  appear  before  mine  eyes  on  the  Piazza  Vittoria,  on  that  fine 
April  day,  before  I felt  an  unusual  attraction  that  drew  me  towards  you  in 
an  extraordinary  fashion.  I have  been  following  you  and  waiting  for  you 
for  ever  so  many  days,  and,  in  short,  I love  you  with  a love  that  is  greater 
and  more  powerful  than  ever  love  was  before,  for  it  has  reached  that  point 
in  which  there  is  nothing  left  for  me  but  to  marry  or  to  die.  . . .’ 

In  this  manner  his  present  passion  arose  : On  the  Piazza  Vittoria  he 
saw,  in  her  carriage,  a handsome  young  lady  belonging  to  the  aristocracy. 
He  fell  in  love  with  her,  and,  believing  that  she  returned  his  affections, 
he  wished  to  marry  her.  The  conviction  that  the  lady  was  in  love  with 
him  was  so  deeply  rooted  that,  a few  days  after  his  admission  to  the 
asylum,  he  wrote  to  his  own  sister  as  follows  : 

‘ Dear  Sister, 

‘ I am  at  present  in  an  asylum  owing  to  love  troubles,  but  I hope 
to  leave  it  soon  and  to  marry  a beautiful  lady.  I have  to  ask  you  to  go  at 
once  to  the  registry  office,  and  to  get  them  to  make  out  a certificate 
declaring  that  I am  free  to  marry.’ 

But  what  are  his  proofs  that  the  lady  is  in  love  with  him  ? He  has 
simply  seen  her,  but  has  never  been  able  to  speak  to  her.  He  has  often 
walked  to  and  fro  underneath  her  windows,  but  without  receiving  any 
sign  from  her.  He  has  written  an  infinite  number  of  letters,  but  one  and 

39—2 


6i2 


PSYCHIATRY 


all  of  them  remain  unanswered.  That  ought  to  be  sufficient  to  lead  to  a 
negative  conclusion,  but  it  is  not  so  for  our  patient.  He  believes  that  he 
possesses — perhaps  in  compensation  for  his  ill-developed  genitals — a 
special  fascination,  in  virtue  of  which  no  lady  can  resist  him.  From  his 
boyhood  he  has  always  been  a fascinator,  a bewitcher,  an  enchanter. 
Ladies  have  always  been  falling  in  love  with  him,  and  it  was  not  their 
fault  that  he  did  not  marry  any  of  them.  It  was  the  doing  of  God,  who 
desired  to  preserve  him  for  a stronger  love,  for  a higher  union,  or,  as  he 
writes,  for  ‘ the  fusion  of  two  great  souls  burning  with  love  and  delirium, 
who  will  prove  to  the  world  that  no  happier  passion  can  be  experienced 
than  that  of  their  ardent  and  immeasurable  love.’  If  no  lady  has  ever 
been  able  to  resist  his  fascination,  then  neither  can  she  who  is  the  object 
of  his  present  love,  and  that  is  an  axiom  admitting  of  no  possible  doubt. 
But  he  has  still  further  proof.  He  is  always  writing  letters  to  which  he 
gets  no  direct  replies.  That,  he  says,  is  quite  natural,  because  the  lady 
is  not  at  liberty,  being  closely  guarded  by  her  parents — those  very  parents 
who  have  had  him  shut  up  in  the  asylum.  He,  however,  finds  her  replies 
among  the  correspondence  on  the  fourth  page  of  the  Mattino  and  in  the 
‘ Piccola  Posta  ’ (or  Agony  Column)  of  Gibus  in  the  same  paper.  Every- 
thing he  finds  there  that  could  possibly  have  any  bearing  on  his  own  case 
he  interprets  as  a reply  from  the  lady.  Of  course,  he  selects  only  those 
communications  that  are  favourable  ; the  others,  he  says,  do  not  concern 
him.  He  has  a wonderful  confidence  in  the  ‘ Piccola  Posta  ’ ; for  him  it 
is  an  infallible  code  of  love,  from  which  there  is  no  appeal. 

Then,  he  has  also  dreams,  in  the  testamentary  value  of  which  he  has 
a very  strong  belief.  Here  is  how  he  writes  about  them  to  the  lady  : 

‘ Do  you  believe  in  dreams,  O Signorina  Amabile  ? Certainly  I do, 
for  they  are  the  true  expression  of  the  soul,  and,  indeed,  I firmly  believe 
that  there  can  be  no  love  without  dreams,  for  they  bring  up  the  vision 
of  the  beloved  being  and  of  everything  that  relates  to  and  touches  upon 
his  love. 

‘ Well,  then,  after  so  many  other  dreams,  I had  to-night  the  fairest 
dream  that  I have  yet  had  or  that  ever  I can  have  in  all  my  life.  . . . 
I dreamed  that,  whilst  I was  thinking  of  you  and  you  were  awaiting  a 
hnal  decision,  I received  from  you  a letter  containing  nothing  more  than 
one  single  word,  a simple  word  but  eloquent,  and  that  word,  which  could 
be  read  in  the  middle  of  that  note  in  large  and  shining  characters,  was 
this  : “ Matrimonio.”  ’ 

The  signihcance  of  this  dream  is  clear  and  unmistakable.  He 
is  therefore  loved  by  the  lady,  and  must  get  out  of  the  asylum  in 
order  to  marry  her.  As,  however,  his  liberation  is  being  delayed,  he 
invokes  the  assistance  of  the  lady,  who  could  hasten  it  with  a word  : 

‘ For  forty  days  I have  been  in  this  asylum ; but  while  asylum  it  may 
be  for  others,  it  is  not  so  for  me  and  for  my  love. 

‘ Forty  days  have  passed  and  I am  still  in  this  hell,  powerless  to  rise 
to  that  desired  and  longed-for  paradise,  which  is  yours,  O Signorina 
Amabile.  For  forty  days  I have  placed  before  these  professors  of  ours  a 
j)roblem  that  is  as  simple  as  it  is  natural,  saying  to  them  : “ Think,  sirs, 
that  I love  my  lady,  and  ask  you  for  nothing  more  than  to  set  me  free  to 
marry  her.”  It  must  now  seem  to  them  a crime  if  my  liberation  from  this 
hell  be  longer  delayed,  but  up  till  now  nothing  could  induce  them,  and 
why  ? Because,  they  say,  you  do  not  love  me  at  all,  and  I cannot  give 
them  any  proof  of  your  love. 

‘ In  such  a difficult}^  I must  invoke  your  measureless  bounty  of  love, 
which  I do  not  and  never  have  doubted  a moment,  and  1 say  to  you 


PARANOIA 


613 


with  the  greatest  bitterness,  O Signorina,  let  my  liberation  come  soon, 
so  that  I may  fly  to  you  and  prostrate  myself  at  your  feet,  begging  you 
to  bestow  on  me,  with  the  supreme  bond  of  love,  which  is  marriage,  the 
great  happiness  that  I await  from  you  and  that  none  other  can  or  ever 
will  be  able  to  give  me,  because,  as  I have  always  said  and  as  I now  repeat, 
you  are  the  most  beautiful  of  all  the  angels  that  God  has  ever  sent  me/ 

Thinking  it  quite  impossible  that  the  lady  could  fail  to  be  interested 
in  his  liberation,  or  that  she  should  fail  to  take  some  practical  steps  to 
hasten  it,  he  came  to  the  conclusion  that  the  greatest  obstacle  was  offered 
by  the  doctors  in  the  asylum,  and  to  them  he  wrote  the  following  letter, 
wherein,  besides  his  exasperation,  we  can  note  the  feelings  of  a hyper- 
trophic personality  : 

‘ I have  no  longer  courage  to  insist,  for  suffering  is  always  silent  when 
the  pain  is  great  ; I shall  only  say,  “ Put  it  to  your  own  conscience,  and 
remember  that  the  greatest  cruelty  in  this  world  is  the  condemnation 
and  the  martyrdom  of  the  innocent.  Remember  the  case  of  that  poor 
fellow  Dreyfus — a case  that  revolted  the  conscience  of  all  humanity,  while 
there  was  one  man,  Zola,  who,  in  that  famous  letter  of  his,  set  forth  a 
challenge  involving  the  hatred  of  a nation,  the  fury  of  a military 
organization,  and  the  anger  of  his  own  Government,  an  example  of 
courage  in  a civilian  that  stands  alone  in  the  world. 

‘ For  me  there  will  not  arise  another  Zola,  but  there  is  a God,  who 
judges  the  innocent  and  the  martyrs,  and  so  I repeat  : “ Put  it  to  your 
conscience.” 

‘ ]\Iy  case  is  very  simple  and  can  be  given  in  a few  words  : If  I love  the 
lady  and  desire  to  marry  her,  there  will  be  no  harm  at  all  in  giving  me  my 
liberty. 

‘ Again,  if  I love  the  lady  and  she  cannot  marry  me  there  will  still  be 
no  harm,  for  I have  not  committed,  and  am  not  the  man  to  commit,  any 
bad  action. 

‘ Where,  then,  is  the  insanity  ? A man  is  insane  if  he  loves  a woman 
who  is  already  married  and  cannot  return  his  passion.  Again,  he  who 
desires  to  marry  a Royal  Princess,  or  any  other  woman  with  whom  he  never 
can  be  united,  is  insane  ; but  not  the  man  who  loves  a virgin  whom  he 
can  marry,  for  that  is  a natural  love,  and  merits  praise  rather  than  punish- 
ment. 

‘ Tell  me,  then,  admitting  it  to  be  true  that  the  lady  whom  I love  is  a 
millionaire,  must  I on  that  account  give  up  the  idea  of  matrimony  ? 
Now  I shall  prove  to  you,  if  you  are  still  incredulous,  that  had  I wished 
to  be  a millionaire — that  is  to  say,  to  marry  for  money  and  not  for  love — 
I might  have  been  so  long  ago. 

‘Not  to  speak  of  the  case  of  the  English  lady  whom  I have  already 
mentioned,  here  are  three  others  that  will  prove  the  truth  of  what 
I have  said.  Yesterday,  in  the  course  of  conversation,  one  of  my  com- 
panions in  confinement  began  to  speak  of  two  men  who  are  proverbial 
for  their  wealth.  Sc.  and  Ro.  I do  not  know  whether  the  latter  has  ever 
fallen  in  love  with  any  of  the  numerous  foreign  ladies  here  in  Naples, 
but  as  to  Sc.,  I knew  him  in  Naples,  and  from  a great  many  signs  I judged 
that  he  was  many  times  a millionaire.  I knew  his  daughters  also,  and 
can  even  inform  you  that  one  of  them,  the  youngest,  loved  me,  and  often 
came  to  the  villa  on  foot,  so  that  it  would  have  been  an  easy  matter  for 
me  to  make  a declaration,  but  I refrained  from  doing  so. 

‘ In  another  instance  a Marchioness,  who  was  a millionaire  fifteen  or 
twenty  times  over,  invited  me  to  dinner,  and  I could  not  well  refuse,  as 
I was  at  her  villa  on  official  duty  in  connection  with  the  delimitation  of 
boundaries.  As  I was  seated  at  the  Marchioness’s  right  hand,  I might 


PSYCHIATRY 


614 

have  spoken  to  her  about  her  daughter,  who  was  perhaps  in  love  with 
me,  although  it  is  not  quite  certain,  but  I did  not  say  a single  word. 

‘ Here  is  the  last  instance.  One  fine  day,  as  I was  sitting  in  the  villa, 
there  came  and  sat  alongside  me  a man  who  appeared  from  his  looks  to  be 
a servant  or  a waiter.  He  sat  so  close  that  he  quite  touched  me,  although 
there  was  plenty  of  room.  As  he  talked  with  another  man  who  came  up 
and  stood  in  front  of  him,  he  said,  speaking  of  a young  lady,  “ That  lady 
has  a dowry  of  a million.’’  I learned  her  name  and  might  have  seen  her, 
and  even  to-day  I might  learn  who  she  is,  and  whether  she  loves  me,  or 
whether  I can  make  her  love  me.  Still,  I did  nothing  and  said  not  a word.’ 

Several  points  become  clear  from  this  letter  : his  conviction  that  he 
can  make  any  woman  fall  in  love  with  him  (defect  of  judgment,  detach- 
ment from  reality)  ; the  length  of  time  for  which  he  has  had  that  convic- 
tion ; the  contrast  between  his  consciousness,  filled  with  erotic  but 
platonic  ideas  and  desires,  and  his  defective  sexual  evolution  ; and  the 
fact  that  he  has  never  even  had  any  fear  as  to  possible  persecution 
throughout  the  whole  course  of  development  of  the  erotic  delirium. 


Paranoia  Qucerula  and  Processomania  (the  Mania  for  Litigation). 

As  a matter  of  fact,  these  are  not  the  same  thing.  Querulous 
persons  are  not  all  paranoic,  nor  have  they  all  the  same  tendency 
to  indulge  in  lawsuits.  In  large  asylums  patients  are  often  met 
with  who  are  continually  complaining  of  something  that  never 
happened  to  them,  and  are  always  accusing  someone.  They  are 
always  in  the  same  frame  of  mind — discontented  with  everything 
and  everybody,  unadaptable,  prone  to  retaliate  and  to  denounce. 
Such  people  are  also  met  with  in  ordinary  life.  As  often  happens, 
they  may  be  possessed  of  fortune  greater  than  their  intelligence 
would  warrant,  yet  they  are  always  complaining  of  their  lot  and 
regarding  the  good  fortune  of  others  with  envy. 

On  the  other  hand,  there  are  families — and  their  history  could 
be  better  reconstructed  in  some  provincial  communities — who  have 
ruined  very  considerable  inherited  estates  by  their  love  of  litigating 
about  the  very  slightest  supposed  infraction  of  some  right  of  theirs, 
families  who  have  nourished  for  several  generations  an  indomit- 
able hatred  towards  other  families,  their  rivals  in  riches  and  in 
power,  until  they  have  squandered  all  their  means  in  keeping  the 
proceedings  going.  In  those  families  one  may  always  find  a paranoic 
subject,  an  epileptic,  an  alcoholist,  a reckless  gambler  and  card- 
player,  or  an  imbecile. 

According  to  my  experience,  the  litigious  disposition  is  always 
a morbid  characteristic  that  arises  from  a passional  irritability  of 
the  ego,  and  from  obsession  with  a basis  of  emotiveness,  pride,  and 
imper\dousness  to  the  current  of  opinion,  whereby  the  error  of  their 
W'dys  does  not  become  plain  to  them.  The  first  class  belong  to  the 
group  of  the  ‘ Querulirenten  ’ of  the  Germans  ; the  second  are 
better  classed  under  the  name  of  litigious  maniacs. 


PARANOIA 


615 


The  mania  for  litigation  depends  upon  an  exaggerated  sentiment 
of  proprietorship,  associated  with  a defective  conception  of  the 
rights  of  property  belonging  to  others.  These  two  elements  may 
be  found  separately,  or,  as  is  more  frequently  observed,  in  con- 
junction in  the  same  individual,  but  in  various  proportions  in 
different  cases.  The  psychic  figure  of  the  querulous  insane  is  sub- 
stantially the  same  as  that  of  the  proud,  persecuted  paranoiac.  So 
long  as  we  are  dealing  with  a passional  tendency  to  institute  legal 
proceedings,  due  to  the  psychic  conditions  above  mentioned,  we 
shall  speak  of  the  mania  for  litigation.  In  many  cases  it  is  a 
paranoid  state  rather  than  real  paranoia,  into  which  latter  it  passes 
by  degrees. 

In  querulous  paranoia  a frequent  characteristic  is  a true  delirium 
of  persecution  (paranoia  persecutoria  qu^erulans,  the  ‘ Quserulanten- 
wahnsinn  ’ or  ‘ Quserulantenirrsinn  ’ of  the  Germans). 

In  this  case,  not  only  does  there  exist  an  intellectual  defect, 
preventing  the  perception  of  the  limits  of  one’s  own  rights,  and, 
translating  itself  into  a defect  in  the  concrete  conception  of  pro- 
perty, but  there  is  also  great  affective  excitability,  not  to  speak  of 
a permanent  state  of  excitement,  hurtful  to  the  ego,  and  an  exalted 
sentiment  of  one’s  own  rights.  Further  than  that,  there  is  a true 
delirium  of  persecution,  which  follows  a course  of  evolution  similar 
to  that  of  other  deliria  of  the  same  class,  constantly  widening  the 
sphere  of  its  action,  and  comprising  even  the  constituent  bodies  of 
the  State,  which,  according  to  the  litigious  maniac,  do  not  fulfil 
their  duty,  are  subject  to  extraneous  influences,  and,  instead  of 
admitting  his  rights,  which  have  been  maliciously  trampled  upon, 
deal  still  more  unjustly  with  his  misfortune  and  his  misery. 

A legal  process,  generally  concerned  in  the  tangled  arguments  of 
these  sufferers,  though  it  may  have  a legitimate  basis,  is  dragged 
from  court  to  court,  without  any  sense  of  propriety  or  of  the 
importance  of  the  circumstances.  In  their  impatience  to  obtain 
justice  these  subjects  call  in  new  advocates  from  amongst  those 
most  in  repute  at  the  time,  and  should  the  latter  refuse  to  take 
up  the  case,  that  is  for  them  a further  proof  that  they  are  being 
subjected  to  persecution.  Should  the  suit  not  be  carried  to  a 
favourable  conclusion,  through  some  fault  of  procedure,  or  if  the 
verdict  be  adverse,  or,  again,  if  the  case  be  abandoned  by  advocates 
who  have  taken  it  up  under  misapprehension,  then  the  litigious 
maniac  appeals  to  the  great  authorities  of  the  State,  to  the  Prefect, 
to  the  Procurator-General  of  the  Court  of  Appeal,  to  the  Keeper  of 
the  Seals,  or  even  to  the  King.  These  persons  usually  give  credence 
to  the  tales  of  injustice  suffered,  but  can  do  nothing.  After  such 
efforts  have  proved  useless,  recourse  is  had  to  the  press,  in  which 
sensational  articles  are  inserted.  Even  those  articles  fail  to  alter 
matters,  and  the  injured  ones  then  create  a disturbance  or  make 
some  threat  or  other,  with  the  sole  object  of  calling  the  attention 


6i6 


PSYCHIATRY 


of  the  authorities  to  their  case.  Finally,  they  are  confined  in 
asylums. 

I have  never  seen  a case  of  this  sort  with  hallucinations  (see, 
however,  De  Sanctis,  Rivista  Sper.  di  Fren.,  1898  ; Guicciardi, 
ihid.  ; and  the  invaluable  monograph  of  Hitzig,  Ueher  den 
Querulantenwahnsin,  Leipzig,  1895). 

I give  here  a short  history  of  a former  inmate  of  this  asylum. 

Observation  XXIL— P.  Gaetano  was  admitted  to  the  Provincial 
Asylum  of  Naples  for  the  first  time  in  1883,  and  remained  there  only  a few 
days.  He  came  of  healthy  parents,  and,  so  far  as  we  have  been  able  to 
ascertain,  there  had  never  been  any  case  of  neuropathy  in  his  family. 
He  attended  an  elementary  school,  and  when  he  had  completed  his  course, 
at  a little  more  than  fifteen  years  of  age,  his  father  placed  him  in  a hatter’s 
shop,  which  he  conducted  with  varying  fortune  ; ultimately,  however, 
he  succeeded  in  improving  his  financial  position  so  as  to  be  able  to  accumu- 
late a capital  of  40,000  or  50,000  lire.  In  1859  married.  There  were 
several  children  of  this  marriage,  but  of  these  only  one  girl  survives.  His 
wife  died  in  1866.  He  married  again,  and  by  his  second  wife  he  had  other 
seven  children,  of  whom  five  are  alive.  It  was  after  the  second  marriage  that 
his  troubles  commenced.  A sister-in-law  who  did  not  succeed  in  drawing 
him  into  the  net  that  she  had  spread  in  order  to  estrange  him  from  his  wife, 
threatened  that  she  would  alienate  his  wife  from  him,  and  would  reduce  him 
to  beggary.  Some  time  after,  that  woman  managed  to  persuade  his  wife  to 
go  and  live  with  her.  All  the  rooms  were  cleared  of  furniture,  and  he  was 
left  alone  in  an  empty  house.  This  performance  induced  him  to  lodge  his 
first  complaint  against  his  sister-in-law.  No  attention,  however,  was  paid 
to  that  first  complaint,  because,  he  maintains,  the  Public  Procurator 
was  bribed.  As  he  did  not  get  the  legitimate  satisfaction  that  he  expected, 
if  his  own  assertions  can  be  believed,  he  commenced  to  appeal  to  the  King, 
then  to  the  Keeper  of  the  Seals.  For  that  purpose  he  had  twice  to  go  to 
Rome,  and  meanwhile  his  business  was  going  wrong.  As  a matter  of  fact, 
some  one  took  advantage  of  his  credulity ; he,  however,  did  not  recognise 
the  real  cause  of  his  ruin,  but  conceived  a veritable  delirium  of  persecution, 
and,  instead  of  trying  to  restore  the  fortunes  of  the  family  by  profitable 
industry,  he  began  fresh  lawsuits  for  supposed  damage  and  injury  to  his 
rights,  so  that  in  a short  time,  though  he  was  without  the  means  of  sus- 
tenance, he  was  involved  in  as  many  as  fifteen  lawsuits.  As  some  of  these 
lawsuits  turned  out  badly  and  caused  the  loss  of  some  of  his  property, 
his  delirium  of  persecution  was  thereby  fed  to  such  a degree  that, 
owing  to  his  outbreaks,  the  loss  of  sleep,  his  refusal  to  eat,  his  violence, 
and  the  noise  he  made  in  the  halls  of  the  Palace  of  Justice  or  in  the  ante- 
chambers of  the  Questor’s  office,  it  became  necessary  to  send  him  to  the 
asylum.  There  he  relates  the  story  of  his  doings  for  hours  at  a time, 
telling  of  his  pilgrimages,  his  anxieties,  the  injustice  that  he  has  suffered, 
and  the  way  in  which  his  rights  were  trampled  upon.  He  tells,  to  the 
rnost  minute  detail,  the  way  in  which  he  presented  his  petition  to  the 
King,  and  what  he  said  to  the  Ministers  and  other  judicial  authorities. 
He  enters  into  particulars  that  have  not  the  slightest  connection  with  the 
]U'oof  he  wishes  to  give  of  his  rights. 

He  s]:>eaks  for  hours  at  a time,  making  accusations  against  the  magis- 
trates and  political  authorities  and  the  doctors  in  the  asylum,  who  do  not 
give  sufficient  attention  to  his  stories.  He  passes  with  extraordinary 
rapidity  from  the  reasons  for  one  lawsuit  to  those  for  another,  stating  the 
dates,  ]:>ersons,  and  localities  with  the  aid  of  a sure  and  very  faithful 
memory.  Still,  however  much  he  may  be  questioned,  he  can  never  tell 


PARANOIA 


617 


what  is  the  true  crux  of  the  matter,  for  that  completely  escapes  him.  The 
whole  matter  is  reduced  to  a false  conception  of  his  rights  and  to  a pro- 
found defect  of  appreciation  of  the  limits  of  those  rights — to  an  exalted 
self-esteem  and  to  the  false  conception  of  an  extensive  system  of  persecu- 
tion, direct  on  the  part  of  those  persons  who  are  nearest  him,  and  indirect, 
in  so  far  as  the  judicial  authorities  and  the  other  departments  of  State 
either  have  failed  to  defend  him  or  have  been  bribed  to  join  in  bringing 
about  his  final  ruin.  The  finishing  touch  of  all  this  is  found  in  the  last 
extremity  of  the  malice  of  his  enemies  and  of  the  public  authorities  in 
sending  him  to  the  asylum — a proceeding  against  which  he  protests 
energetically,  declaring  that  he  is  really  of  sound  mind,  and  claiming 
his  right  to  that  liberty  which  will  enable  him  better  to  protect  his  own 
interests  and  to  continue  judicial  proceedings  against  all  those  aforesaid 
persons,  and  others,  too,  by  whom  he  believes  himself  to  have  been 
injured  in  his  rights. 

We  have  never  been  able  to  detect  any  hallucination  or  even  an  illusion. 
Before  he  entered  the  asylum  he  had  got  to  the  end  of  all  his  means. 
For  several  months  he  came  frequently  to  me  to  ask  my  protection  and 
letters  of  recommendation  to  the  political  and  judicial  authorities,  whom 
he  had  caused  no  end  of  annoyance.  In  the  meanwhile,  owing  to  lack  of 
food  and  shelter,  he  had  become  thin,  pale,  and  so  reduced  in  strength 
that  he  could  hardly  stand  on  his  legs,  and,  out  of  pity,  I myself  had 
finally  to  take  steps  to  get  him  admitted  into  the  asylum  this  last  time. 
There  he  found  comparative  quiet,  and  his  health  became  restored.  Some 
periodicals  took  up  his  case  at  great  length. 

The  diagnosis  of  paranoia  is  founded  on  the  character  that  has 
been  assigned  to  it  at  the  beginning  of  this  chapter.  To  arrive  at 
a clear  understanding  of  this  group  of  psychopathies,  it  is  advan- 
tageous to  exclude  from  the  class  of  paranoia  all  manifestations  of 
apparently  systematized  delirium  that  represent  episodes  of  other 
maladies  which,  in  their  course,  the  complexity  of  their  phenomena, 
their  result,  but  especially  in  their  mode  of  onset,  have  a recog- 
nisable figure  of  their  own,  distinct  from  that  of  paranoia.  This 
advantage  is  much  greater  still  as  regards  the  course  and  the  result 
of  the  malady.  For  similar  reasons  of  a strictly  psychological  and 
clinical  nature,  every  confusional  or  acute  hallucinatory  form  that 
leads  to  amentia  or  dementia  prcBcox  must  be  excluded  from  the 
held  assigned  to  paranoia.  So  also  must  we  exclude  those  syste- 
matized deliria  that  follow  immediately  upon  a primary  malady 
without  any  intervening  period  of  mental  sanity — well-defined 
acute  psychopathies,  and  particularly  melancholia  and  sensory 
deliria.  Such  consecutive  systematized  deliria  form  the  large 
group  of  secondary  paranoias,  and  are  better  considered  along 
with  secondary  dementia,  as  they  represent  only  the  results  of 
primary  mental  maladies.  These  forms  sometimes  end  in  re- 
covery. 

I do  not  include  among  the  secondary  paranoias  that  form  which 
occurs  some  time  subsequently  to  an  acute  sensory  psychosis  that 
has  ended  in  recovery.  In  such  cases  there  is  developed  at  a late 
period,  by  a process  of  unconscious  cerebration,  a persecutory  or 
a religious  delirium  of  slow  evolution,  the  roots  of  which  must  be 


6i8 


PSYCHIATRY 


sought  in  the  more  active  and  predominant  hallucinations  of  the 
primary  affection  ficni  which  the  patient  recovered.  , 

Paranoia,  as  dealt  with  in  this  chapter,  is  always  a chronic 
malady.  It  is  to  be  considered  as  a whole,  but  more  particularly 
in  its  origin  and  its  course.  It  presents  a physiognomy  that  can- 
not be  confused  with  any  other,  if  due  account  be  taken  of  the 
clinical  features  already  discussed. 

Among  the  paranoias  should  be  included  those  systematized 
deliria  of  content  identical  with  the  forms  of  paranoia  just  described, 
but  of  short  duration,  and  succeeded  by  the  normal  state,  except 
in  cases  of  relapse.  These  are  the  paranoic  deliria  of  degenerates. 
In  such  cases,  in  addition  to  the  signs  of  psychic  degeneration,  there 
exist  those  also  of  the  paranoic  character.  The  rapidly  evolved 
delirium  is  nothing  else  than  an  acute  episode  of  relapse  of  the 
paranoic  character. 

Course. — As  we  have  already  said,  paranoia  runs  an  extremely 
long  course.  Sometimes  the  delirium  remains  circumscribed,  just  as 
it  was  originally  conceived,  but  in  other  cases  the  whole  personality 
becomes  involved,  after  a longer  or  shorter  period  of  time.  I have 
still  under  observation  paranoic  subjects  who  were  examined  by  ' 
me  when  the  psychiatric  clinique  was  first  instituted  in  Naples 
some  twenty-two  years  ago,  and  some  of  them  still  preserve  fairly  i 
good  logical  power.  Some  paranoiacs  show  phenomena  of  mental  ' 
decadence  at  a very  early  period — e.g.,  the  subject  of  Observation  , 
tion  XIX.,  p.  596.  Others,  again,  continue  for  many  years  in  the  ' 
same  condition,  the  only  difference  being  that  the  delirium  is  much 
more  active  and  more  clearly  determined  at  the  beginning,  losing 
its  vivacity  as  time  goes  on,  and  as  the  patients  become  better  ' 
adapted  to  their  environment,  less  threatening,  less  impulsive,  and  ] 
able  to  occupy  themselves  in  some  useful  work.  ! 

States  of  mental  decadence,  characterized  by  authors  as  pseudo-  j 
dementia,  are  more  or  less  marked,  and  make  themselves  evident  \ 
at  an  earlier  or  later  period,  according  to  conditions  peculiar  to  each  I 
individual.  As  a rule,  it  may  be  said  that  paranoiacs  with  halluci- 
nations suffer  mental  decay  much  sooner  than  those  without  hallu- 
cinations. There  may  be  a respite  in  the  course  of  the  paranoia, 
and  sometimes  there  may  even  be  an  apparent  recovery. 

In  such  a case  the  patient  realizes  the  falsity  of  his  delirious 
ideas,  and  resumes  his  position  in  the  social  life ; but,  unless  it  be 
the  neurasthenic  form  of  paranoia,  which  I have  placed  in  the 
second  group,  this  respite  is  usually  brier. 

Generally  speaking,  the  remissions,  and  sometimes  the  recoveries, 
belong  to  primary  paranoia  without  hallucinations. 

Episodes  of  hallucinatoiy  mental  confusion  are  not  rare,  especi- 
all}^  at  the  beginning. 

Death  occurs,  even  at  an  advanced  age,  from  intercurrent  I 
maladies. 


PARANOIA 


619 


f 

We  know  nothing  of  the  pathological  anatomy  of  primary 
paranoia.  The  whole  structure  that  Wernicke  has  built  upon  the 
concept  of  the  interruption  of  the  association  paths,  upon  which 
he  has  formulated  the  doctrine  of  the  disjunction  of  the  psychic 
, components  (the  disjunction  hypothesis),  is  utterly  without  a basis 
■ of  observation. 

The  therapy  reduces  itself  to  the  methods  of  dealing  with  the 
separate  phenomena — the  great  excitability,  the  more  vivid  hallu- 
cinations, the  psychomotor  exaltation,  and  the  vasomotor  pheno- 
mena. These  must  be  treated  on  the  general  principles  laid  down 
elsewhere  in  this  book. 

The  paranoiac  is  almost  always  dangerous  to  himself  and  to  those 
about  him,  and  the  prompt  intervention  of  the  alienist  frequently 
prevents  incalculable  damage.  He  is  a subject  in  whose  case  con- 
finement and  supervision  are  urgently  called  for,  more  so  than  in 
almost  any  other ; but,  unfortunately,  society  cannot  always  protect 
itself  against  the  injuries  it  suffers  from  paranoiacs. 


CHAPTER  IX 


FIXED  IDEAS  AND  OBSESSIONS  i 

The  malady  of  fixed  ideas,  or  in  a larger  sense  of  obsessions,  is 
represented  by  a psychic  fact  with  an  asthenic  and  emotive  basis, 
determined  most  frequently  by  some  percept  that  cannot  be  assimi- 
lated, and  that  remains  implanted  in  the  consciousness  as  an  ex- 
traneous element,  without  disaggregating  or  decomposing  the  per- 
sonality ; or  the  percept  may  be  recalled  under  identical  conditions! 
of  existence,  with  its  whole  cortege  of  emotions,  more  or  less  in  | 
contrast  or  in  combat  with  the  consciousness,  which  usually  suc-| 
cumbs  after  all  its  means  of  defence  have  been  gradually  exhausted.  ’ 
With  regard  to  the  nature  of  the  obsessions,  I could  not  give  a 
clearer  notion  of  them  than  by  using  an  analogy  which  appears  to^ 
me  to  give  the  most  perfect  idea  of  this  very  important  group  of 
psychopathies.  I take  it  from  ordinary  physio-pathology,  the  facts 
and  laws  of  which  are  too  often  neglected  in  the  interpretation  of!j 
psychic  phenomena.  It  is  now  known  that  in  psychic  life  we  meet  | 
with  the  same  laws  as  regulate  and  govern  organic  life.  An  organism 
lives,  evolves,  and  adapts  itself  only  in  proportion  as  it  has  the  power 
of  prompt  assimilation,  disassimilation,  and  elimination,  according  ! 
to  the  known  laws  of  biology.  Proper  assimilation  means  the ' 
appropriation  of  the  organic  and  inorganic  elements  that  are  advan-'l 
tageous  or  indispensable  to  life  ; good  elimination  means  the  getting^* 
rid  of  extraneous  elements  that  have  penetrated  into  the  organism,^ 
or  of  the  products  of  disassimiliaton  that  are  hurtful,  or  of  no 
service  to  the  living  being. 

Wherever  these  conditions  are  not  rigorously  maintained,  life 
becomes  impossible,  or  else  it  is  poor,  abnormal,  and  curtailed.  It 
is  well  known  that  there  is  a whole  group  of  organic  diseases  in 
which  this  fundamental  biological  function  is  altered,  and  everyone 
knows  the  importance  that  this  conception  has  recently  acquired 
in  the  development  and  the  progress  of  human  pathology. 

The  processes  of  mental  life  follow  similar  courses.  A well- 
organized  mind  must  select  and  assimilate  from  amongst  the 
numerous  sensory  factors  those  that  will  be  serviceable  for  its 
development,  and  will  associate  with  other  psychic  elements  in 

620 


FIXED  IDEAS  AND  OBSESSIONS 


621 


order  to  constitute  the  more  complex  and  higher  mental  products, 
in  which  is  summed  up  the  concept  of  the  evolution  and  progress 
of  the  indi\ddual,  as  a unit  in  harmony  with  his  environment.  It 
must  also  eliminate  those  psychic  elements  that  cannot  be  utilized 
for  the  purposes  of  mental  life.  Through  a power  intrinsic  to  its 
own  organism  the  mind  eliminates  all  that  will  not  serve  the  final 
end  of  man  as  an  individual  and  as  a social  unit.  Of  the  millions 
of  stimuli  and  impressions  that  impinge  upon  the  senses  and  the 
perceptive  centres  of  man,  reaching  or  crossing  the  threshold  of 
consciousness,  not  one  is  lost,  and  if  only  a relatively  small  portion 
of  them  should  become  a patrimony  that  can  be  made  use  of,  ready 
always  to  be  vivified  and  re-evoked  into  consciousness,  the  remainder 
will  be  eliminated  and  lie  buried  at  the  bottom  of  the  great  ocean 
of  ‘ the  unconscious,’  thence  possibly  to  rise  to  the  surface,  in  some 
tempestuous  or  abnormal  perturbation  of  the  mind.  In  minds  that 
are  badly  organized  (morbid  heredity  or  other  degenerative  influ- 
ences) it  may  happen  that  the  process  of  psychic  metabolism  is 
interfered  with,  and  that  a psychic  component,  destined  to  pass 
transiently  over  the  field  of  consciousness  and  to  fall  into  ‘ the 
unconscious,’  remains  in  the  mind,  and  cannot  be  eliminated,  just 
as  it  sometimes  happens  that  some  poisons  developed  in  the 
organism,  or  some  substances  introduced  from  without,  cannot  be 
expelled,  but  remain  and  accumulate  in  the  organism.  These 
psychic  elements  that  have  not  been  eliminated  are  ‘ obsessions.’ 
Once  they  have  passed  over  the  threshold  of  consciousness,  they 
remain  there  as  products  that  cannot  be  assimilated,  extraneous  to 
the  processes  of  mental  metabolism,  which  is  interfered  with,  or 
even  wholly  prevented  by  them. 

The  psychic  personality  becomes  painfully  aware  of  their 
presence  and  their  irrational  recurrence.  It  feels  the  effects  of 
the  desolating  action  of  these  ruthless  invaders  ; it  recognises  its 
own  inferiority  in  face  of  these  unbridled  and  uncontrolled  elements  ; 
it  reacts  with  greater  or  less  force  to  free  itself  from  them,  but 
often  without  any  other  result  than  that  of  assisting  them  in  their 
conquest. 

At  this  point  I think  it  advisable  to  trace  the  limits  of  the  con- 
cept of  fixed  ideas  and  obsessions.  Every  idea  that  arises  in  the 
consciousness  with  the  potentiality  of  development,  and  that  has 
the  virtue  of  directing  the  activity  of  a man’s  life,  and  guiding  it 
towards  some  end,  is  not  necessarily  a fixed  idea.  An  infinite 
number  of  ideas  and  percepts  become  the  special  psychic  patrimony 
of  each  man,  and  there  are  others  that  dawn  in  the  consciousness 
of  one  or  several  men,  assume  directive  power,  wind  the  resources 
of  the  intellect  in  ever-increasing  coils,  extend  their  sphere,  caress 
the  mind  of  the  individual  or  illuminate  the  consciousness  of  a people, 
and,  after  they  have  been  transmitted  from  generation  to  genera- 
tion, incarnate  the  principle  that  animates  a period  of  history. 


622 


PSYCHIATRY 


These  are  not  fixed  ideas.  They  are,  as  it  were,  the  regulative  i 
centre  of  a whole  constellation,  of  a sidereal  system,  to  adopt  the  i 
expression  of  Ziehen.  They  are  the  offspring  of  the  most  varied  ! 
social  and  historical  conditions,  and  at  the  same  time  they  become  ! 
a fixed  and  luminous  point,  serving  as  a guide  for  a man  or  a whole  j 
society  in  the  march  across  the  steppes  of  time.  ' 

These  are  ideas  of  high  nutritive  power  ; they  are  assimilated 
to  the  personality,  to  which  they  impart  their  own  colouring,  and 
to  which  they  communicate  the  movement  that  is  intrinsic  to  their 
own  nature. 

All  the  ideas  assimilated  to  and  fused  in  the  personality, 
immediate  products  of  the  percepts  or  more  complex  products, 
such  as  the  concepts,  should  never  be  considered  as  fixed  ideas.  I 
The  existence  of  obsession  demands  certain  indispensable  condi- 
tions, and  these  reveal  the  morbid  character  of  the  soil  on  which  this  i 
evil  growth  germinates.  Those  conditions  are  : I 

1.  Excessive  emotivity;  for  emotion,  while  arresting  the  move-  ' 
ment  of  the  ideas  of  defence  in  the  consciousness,  offers  to  external  I 
stimuli  conditions  suitable  for  the  strongest  impression,  thus 
favouring  the  persistence  of  the  emotion  itself  and  of  the  relative  , 
images. 

2.  Congenital  or  acquired  weakness  of  the  mental  organization. 
This  co-operates  in  two  ways.  On  the  one  hand,  it  favours  the 
obsession  through  the  paucity  of  ideas  or  emotions  of  defence,  and,  ,| 
on  the  other  hand,  it  renders  less  vivid  and  active  those  that  have 
the  power  to  drive  out  or  to  eliminate  from  the  consciousness  the 
useless  parasitic  products  in  which  the  concept  of  the  obsession  is  ^ 
contained.  Before  we  can  speak  of  fixed  ideas  and  of  obsessions,  we 
must  have  the  other  essential  condition  that  these  be  incapable  of 
assimilation  with  the  psychic  personality  at  the  historical  moment ; in  , 
other  words,  there  must  be  a continual  struggle  between  the  ideas  and  ; 
the  consciousness.  The  fixed  ideas  are  importunate  guests  from  whom  . 
the  conscious  personality  would  like  to  free  itself,  because  they  are  ' 
irrational  ; but  it  does  not  succeed  in  this.  Therein  lies  the  essential 
difference  between  fixed  ideas  and  paranoia,  and  for  that  reason  ^ 
I consider  the  classification  of  fixed  ideas  amongst  the  paranoias 
to  be  a cause  of  confusion,  although  such  a course  has  been  followed 
by  Kirn,  Krafft-Ebing,  Arndt,  Morselli,  and  Spitzka,  the  last  of 
whom  described  the  fixed  idea  under  the  name  of  ‘ abortive  mono- 
mania,’ corresponding  to  the  rudimentary  paranoia  of  Arndt  and 
[Morselli.  In  paranoia  there  is  a transformation  of  the  personality 
in  the  sense  that  the  delirious  idea  is  assimilated  with  the  con- 
sciousness, and  imprints  on  it  all  those  characteristics  belonging  to 
it,  as  well  as  a course  of  conduct  in  social  relations  that  is  inherent 

in  the  nature  and  character  of  the  delirium. 

In  the  malady  of  fixed  ideas,  on  the  other  hand,  the  personality 
does  not  undergo  any  transformation  further  than  the  afflicted  tone 


FIXED  IDEAS  AND  OBSESSIONS 


623 


that  arises  from  the  tormenting  despotism  of  ideas  and  emotions 
that  are  recognised  to  be  irrational,  and  from  the  inefftcacy  of  the 
struggle  for  freedom  from  these.  This  difference  had  already  been 
observed  and  clearly  defined  by  Morel,  in  terms  that  do  not  leave 
the  reader  in  any  doubt  as  to  the  clear  conception  of  the  acute 
French  observer;  also  by  Westphal,  in  1877,  and  by  Church.  We 
shall  see  later  on  whether  fixed  ideas  may  become  delirious  ideas, 
and  whether  in  that  case  only  we  may  speak  of  paranoia. 

For  the  moment  let  us  restrict  ourselves  to  the  conception  as 
understood  by  Viorel,  and  let  us  try  to  trace  its  mechanism.  The 
task  here  set  before  psychopathology  is  no  easy  one. 

Most  observers  accord  importance  to  emotivity  and  emotion. 
While  Westphal  and  Krafft-Ebing  consider  the  malady  to  be  an 
ideative  disturbance,  without  the  coexistence  of  an  emotional  or 
passional  state,  and  interpret  the  emotion  as  the  effect  of  the  more 
or  less  violent  and  painful  reaction  of  the  consciousness  that  is 
abused  by  the  obsession,  almost  all  the  French  authors,  from  Morel 
onwards,  like  Fere,  Seglas,  Ballet,  Dallemagne,  Pitres  and  Regis, 
consider  the  fixed  ideas  to  have  their  origin  in  morbid  emotivity. 
The  two  last-mentioned  authors,  who  have  written  the  most  valu- 
able monograph  hitherto  published,  conclude  that  obsession  is  a 
highly  emotional  morbid  state. 

Not  less  numerous  and  authoritative  are  the  German  authors, 
who  maintain  the  same  idea.  It  is  sufficient  to  cite  amongst  them 
Berger  (emotional  neurosis),  Friedreich,  Hans  Kann,  Schfile, 
Wille,  Freud,  and  Hecker,  the  last  two  of  whom  give  to  the  malady 
the  name  of  ‘ neurosis  of  anguish.’  Emotion  does,  in  fact,  constrain 
the  ideative  process  to  the  image  that  it  contains  when  it  has  per- 
ceptive or  ideative  content,  and  it  concentrates  the  perceptive 
power  and  the  attention  almost  exclusively  on  the  image  or  the 
correlated  idea,  which  therefore  tends  to  assume  dominion  in  the 
consciousness,  and  to  bring  about  a condition  of  static  emotion 
therein.  We  must  not,  however,  neglect  the  fact,  which  has  been 
well  set  forth  in  the  publications  of  Tamburini  and  Magnan,  that 
very  often  it  is  the  idea  that  arises  first,  without  any  accompanying 
emotion,  like  a spasm  or  a state  of  tetanus  in  some  part  of  the 
field  of  intellect;  and  the  emotion  that  afterwaids  accompanies  it 
is  due  really  to  the  unusual  vividness  of  the  idea  and  to  a species 
of  shock  that  its  uprisal  gives  to  the  consciousness.  Later  on  it 
is  to  be  ascribed  to  arrest  of  the  interchange  of  ideas,  and  to  the 
inefficacious  struggle  of  the  revolted  consciousness  in  its  endeavours 
to  free  itself  from  the  abnormal  product.  While,  therefore,  we 
admit  that  emotion  always  accompanies  a fixed  idea  to  a certain 
extent,  although  the  emotional  state  does  not  of  itself  con- 
stitute the  painful  static  condition  of  the  consciousness,  we  must 
acknowledge  that  there  are  cases  in  which  the  malady  arises  directly 
from  the  field  of  intellect,  and  is  only  subsequently  accompanied 


624 


PSYCHIATRY 


by  emotion.  At  the  same  time,  there  are  other  cases,  as  observed 
by  Pitres  and  Regis,  in  which  the  emotion  becomes  reduced  in 
proportion  as  the  malady  is  confirmed  and  assumes  more  of  an 
intellectual  character. 

Some  authors  consider  that  this  malady  consists  essentially  in 
weakness  of  will  (Magnan,  Legrain,  Ballet).  No  great  expenditure 
of  words  is  required  to  demonstrate  the  improbability  of  such  a 
hypothesis.  It  is  sufficient  merely  to  remember  that  the  ideative 
process  and  the  association  of  the  elements  of  the  intellectual 
patrimony  are  regulated  by  laws  to  which  the  will  is  extraneous. 

At  the  utmost  the  will  has  power  only  to  concentrate  the  atten- 
tion on  a group  of  ideas,  and  to  direct  the  process  of  thought  towards 
an  idea,  around  which  are  subsequently  represented  and  developed, 
according  to  intrinsic  norms,  all  the  related  intellectual  material 
that  each  man  has  at  his  command. 

But  even  this  regulative  and  directive  power  that  the  will 
exercises  over  thought  lasts  for  a comparatively  short  time.  As 
soon  as  it  becomes  fatigued,  extraneous  thought  invades  the  field, 
which  has  hitherto  been  closed,  by  voluntary  attention,  against 
all  ideas  not  related  to  the  special  theme.  Nowadays  there  is  no 
psychologist  who  will  argue  that  the  process  of  thought  is  subject 
to  the  will. 

On  the  other  hand,  if  we  bear  in  mind  the  very  strenuous  efforts 
to  which  those  unfortunate  persons  afflicted  by  the  malady  in; 
question  will  brace  themselves  repeatedly,  in  their  desire  to  set 
themselves  free  from  their  tortures,  we  shall  be  convinced  that  it 
is  not  their  wills  that  are  defective,  and  that  the  will,  which  is! 
vigorous  though  inefflcacious,  is  subject  to  the  inevitable  law  that 
governs  the  formative  process  of  thought  even  in  individuals  whose 
mental  organisms  are  weak  in  all  other  lespects. 

Nor  does  the  doctrine  maintained  by  Ribot  appear  to  me  to  be  ? 
more  happy — namely,  that  the  malady  is  nothing  else  than  chronic 
hypertrophy  of  the  attention.  Ribot  holds  that,  as  in  the  normal ) 
individual  attention  has  a temporary  predominance  over  an  intel 
lectual  state  or  successive  states,  so  in  the  case  of  the  hxed  idea  ^ 
that  predominance  is  absolute,  lasting,  and  more  intense.  The 
sole  truth  appears  to  be  that  in  the  malady  of  obsessions  a very 
limited  group  of  cells  performs  its  function  ; but  anyone  may 
convince  himself  that  attention  is  only  a secondary  state  of  mind, 
and  necessarily  consecutive  to  the  uprisal  of  a group  of  images  and 
of  emotional  states  that  surprise  and  subjugate  the  consciousness. 
It  is  the  law  of  intensity  of  stimuli  that  determines  attention  and 
the  order  of  thoughts  (see  Part  II.).  The  fixed  idea  that  surprises 
the  consciousness,  especially  when  accompanied  by  an  emotional 
state,  attracts  attention  to  itself,  and  the  hypertrophy  is  therefore 
an  effect  and  not  a cause. 

The  formative  process  of  thought,  the  intensity  of  ideas  and  of 


FIXED  IDEAS  AND  OBSESSIONS 


625 


groups  of  ideas,  the  succession  of  constellations  or  of  ideative 
systems,  the  changes  of  states  of  consciousness  along  with  the 
alternation  of  ideas  and  the  corresponding  emotions,  the  ever- 
changing  directive  power  of  the  environment  on  tlie  products  of 
thought  and  on  the  states  of  mind,  the  instability  of  the  kinsesthesis 
in  weak  organisms,  regulating  in  its  turn  the  course  and  nature 
of  thoughts,  are  all  decisively  withdrawn  from  the  regulative  in- 
fluence of  the  will  and  the  attention.  The  sole  essential  law  is  the 
interchange  of  ideas  and  emotionsin  the  consciousness,  the  selection 
that  the  mental  organism  makes,  on  its  own  account  and  by  virtue 
of  its  own  powers,  from  amongst  the  percepts  and  the  complex 
mental  products,  and  the  rapid  and  immediate  elimination  of  all 
those  useless  and  unassimilable  products  that  are  not  in  conformity 
with  the  character  of  the  personality,  but  rather  in  open  contrast 
with  its  nature,  habits,  and  inclinations. 

Such  elimination  is  spontaneous,  and  is  not  determined  by  will 
or  by  attention.  Good  ideas  are  those  that  contribute  to  life  and 
to  the  increment  of  the  psychic  personality,  and  that  exercise  a 
veritable  phagocytic  power  over  the  other  useless  parasitic  and 
toxic  ideas  as  soon  as  they  cross  the  threshold  of  consciousness. 

I say  ideas,  but  the  same  thing  applies  to  any  form  of  psychic 
activity.  Percepts,  the  various  emotions,  concepts,  acts,  and  also 
desires,  may  furnish  material  for  obsessions.  As  a rule  the  material 
of  obsessions  is  supplied  by  the  lower  emotions,  frivolous  percepts, 
bitterly  debated  questions  of  metaphysics,  or  desires  that  are  opposed 
by  individual  or  social  propriety.  In  all  of  them  we  may  perceive 
an  inferior  character  of  mind,  for  there  is  no  such  thing  as  an 
obsession  of  elevated  content. 

From  all  we  have  said  it  becomes  clear  that  there  is  no  use  in 
classifying  separate  forms  of  obsession  in  groups  and  giving  them 
special  names,  although  many  psychiatrists  seem  to  find  great, 
pleasure  in  doing  so. 

An  indispensable  and  fundamental  condition  is  congenital  mental 
weakness  (hereditary  neurasthenia),  or  mental  weakness  acquired 
through  abuse  of  the  intellectual  or  other  functions.  Its  differen- 
tiating characteristic  is  the  more  or  less  accentuated  contrast  in 
the  consciousness  subject  to  emotion  ; or,  in  other  words,  the  helpless 
against  the  inroads  of  the  despotic  and  importunate  guest 
(mental  coaction). 

I have  said  that  all  psychic  products  can  form  matter  for  obses- 
sions. We  elect  to  classify  them  in  the  following  order  : 

Emotive  obsessions. 

Ideative  obsessions. 

Impulsive  obsessions. 

This  distinction  is  not  strictly  psychological,  because  just  as 
the  emotions  have  an  ideative  content  and  a motor  intuition,  so 
ideas  involve  motor  intuitions  and  emotions,  and  impulses  always 

40 


626 


PSYCHIATRY 


nave  an  ideative  and  emotive  content.  The  distinction  is  justified  | 
only  by  the  prevalence  of  one  of  the  constituent  elements  of  each  ; 
group.  i 

Westphal  did  not  place  too  high  a value  on  emotive  obsessions,  | 
which  have  been  well  defined  by  Morel  and  by  Tamburini.  H.  Tuke,  ^ 
Tamburini,  Van  Eden,  Regis,  and  Pitres  agree  with  this  classification.  I 

Van  Eden  distinguishes  : 

1.  Obsessive  concepts,  in  which  obsession  starts  from  a precise  ^ 

and  detailed  concept  that  acquires  impulsive  force.  I 

2.  Obsessive  emotions — fear  and  terror  that  dominate  the  will  j 

and  the  reason.  j 

3.  Obsessive  ideas  properly  so  called — the  intellectual  obsessions  | 
of  the  French,  in  which  the  sufferer  cannot  escape  the  obsession  of  j 
thinking  constantly  of  certain  objects. 

4.  Obsessive  impulses — the  irresistible  tendency  to  commit  | 

strange  or  improper  acts.  1 

Pitres  and  Regis  distinguish  : 

1.  States  of  obsession  with  diffuse  anxiety,  or  panophobia.  . 

2.  States  of  obsession  with  systematized  anxiety,  or  monophobia,  i 

3.  States  of  obsession  with  ideas  of  anxiety,  or  monoideism.  I 

It  is  not  clear  whether  this  distinction  leaves  room  for  obsessive  | 

desires,  which  constitute  a prominent  class  of  obsessions.  1 

Obsessive  emotions  are  distinguished  into  repulsions  or  phobias  ^ 
and  imperative  desires.  The  phobias  are  either  general  (pano-  | 
phobia)  or  related  to  one  particular  thing.  I agree  with  most  ' 
authors  that  it  is  proper  to  place  among  the  obsessions  the  so-called 
insanity  of  doubt ; but  let  us  understand  this  point  clearly.  I have  !| 
never  seen  a subject  suffering  from  obsession  w^ho  w^as  not  uncertain  I 
and  hesitating  in  most  of  the  acts  of  his  life.  All  obsessed  persons 
present  this  phenomenon  to  a greater  or  less  extent.  The  doubt  is  , 
a consequence  of  defect  of  judgment  or  of  memory  characteristic  of  a ^ 
state  of  congenital  or  acquired  w^eakness.  It  is  an  inevitable  result  j 
of  the  inefftcacy  of  the  struggle  betw^een  will  and  the  new"  conqueror  ! 
of  the  consciousness.  Being  a secondary  phenomenon  common  to  > 
the  whole  group,  it  does  not  constitute  a malady  per  se.  The  fear  ^1 
of  everything  that  is  unknown  is  a perennial  source  of  doubt.  ■ 
From  the  unhappy  person  wiro  is  afraid  of  being  defiled  by  or 
contracting  infection  from  everything  she  touches,  to  the  mother 
wiio  is  doubtful  of  her  pow’er  to  resist  the  impulse  to  scoop  out 
her  owm  daughter’s  eye,  or  to  the  man  wiro  is  continually  asking 
himself  the  w"hy  and  wherefore  of  the  Creation  and  of  the  Trinity, 
doubt  is  ahvays  revolving  more  or  less  actively  in  the  consciousness 
of  obsessed  persons. 

In  some  cases,  however,  doubt  is  an  obsession  per  sc.  A man  j 
suspects  that  he  has  written  something  offensive  or  hurtful  to  his  i 
own  interests  or  the  interests  of  others  in  a letter  that  he  has  posted,  | 
and  is  driven  to  despair  ; another  man  fears  that  he  has  compro-  : 


FIXED  IDEAS  AND  OBSESSIONS 


627 


raised  himself  politically  by  writing  to  a politician  or  to  a magistrate  ; 
another  is  driven  to  despair  by  the  doubt  that  he  has  uttered  words 
disrespectful  to  the  Deity,  or  that  he  has  rendered  himself  culpable 
in  some  other  fashion  ; still  another  is  really  tortured  by  the  doubt 
that  he  did  not  shut  the  front-door  properly  before  he  went  to  bed, 
and  to  make  sure  of  it  he  rises  once  ; but  the  doubt  recurs,  and 
makes  him  rise  a second,  a third,  or  even  a fourth  time.  In  these 
cases  the  torment  comes  from  the  doubt,  which  the  subjects  them- 
selves recognise  to  be  more  or  less  irrational,  but  which,  however, 
will  persist.  It  is  produced  by  a real  defect  of  synthetic  repre- 
sentative power,  which  is  essentially  sustained  by  a defect  of  the 
kiiicesthesis.  The  subjects  remember  that  they  did  not  pronounce 
the  offensive  words,  that  they  did  not  write  anything  that  would 
compromise  them,  that  they  did  not  commit  grave  faults  ; but  they 
have  no  lucid  representation  of  their  own  acts,  whence  their  doubt 
of  themselves  and  of  the  way  in  which  they  have  acted.  This  is 
a very  common  phenomenon  in  neurasthenic  conditions,  and  in 
many  cases  it  is  a really  characteristic  morbid  state.  It  may  have 
its  origin  in  some  very  commonplace  event,  and  sometimes  it  is 
based  upon  a dominant  idea  or  sentiment  (Freud).  The  field  of  its 
development  is  a profound  alteration  of  the  kinyesthesis.  I here 
give  a brief  report  of  one  of  the  most  interesting  cases  from  my 
private  clinique  : 

young  woman  of  eighteen,  notably  sensual,  in  a very  good 
social  position,  but  with  hereditary  neuropathic  taint,  one  da}^  fell 
asleep  in  the  garden  surrounding  her  house.  On  awakening — 
possibly  she  had  had  a dream  of  a sexual  character,  or  perhaps  it 
was  owing  to  some  sensations  in  the  vagina,  a point  that  I could 
not  ascertain  with  certainty — she  conceived  the  idea  that  a lizard 
had  penetrated  into  her  vagina,  and  this  caused  her  great  anxiety. 
For  two  years  she  was  tormented  by  that  thought  and  the 
accompanying  fear,  even  after  she  had  been  convinced  that  such 
a thing  was  impossible.  She  suffered  real  fits  of  anguish,  with 
perspiration  and  dejection.  Ffer  condition  was  improved  by 
suggestion,  and  matrimony  proved  a cure.  I saw  her  some  time 
afterwards,  and  her  fear  then  was  that  she  was  not  taking  sufficient 
care  of  her  new-born  child. 

From  obsessive  panophobia  we  distinguish  melancholic  pano- 
phobia,  which  is  very  frequent,  and  is  accompanied  by  a state  of 
permanent  anxiety  that  is  a form  of  melancholia.  In  the  former 
class  the  anxiety  is  latent,  and  the  fits  of  anguish  and  fear,  which 
are  known  to  be  irrational,  arise  on  every  slight  occasion.  Cases 
have  been  reported  by  Morel,  Freud,  and  Regis.  This  form  of 
malady  is  not  very  frequent.  Systematized  obsessions,  with  fear  and 
anxiety,  are  referable  to  the  individual  forms  of  common  and  special 
sensibility  in  so  far  as  they  have  a perceptive  or  ideative  content. 

40 — 2 


628 


PSYCHIATRY 


Tn  the  case  of  tactile  sensibility  the  prototypes  are  rupophobia  I 
and  mysophobia  (the  fear  of  dirt).  The  subjects  of  this  form  of  I 
phobia  are  for  the  most  part  young,  of  the  female  sex,  and  belonging  | 
to  the  well-to-do  and  educated  classes.  They  are  afraid  of  dirtying  [ 
themselves  or  of  contracting  infection  by  touching  any  object  | 
whatsoever.  They  never  shake  hands  ; they  very  seldom  sit  down  ; 
they  wash  every  time  they  are  obliged,  for  some  imperative  reason,  i 
to  touch  an  object,  even  should  it  be  their  own  clothing,  and  they 
may  thus  pass  hours  and  hours  washing  themselves.  A certain 
distinguished  young  lady  never  went  to  breakfast  before  two  or 
three  o’clock  p.m.,  and  passed  all  the  time  from  eight  in  the  morning  . 
till  then  in  dressing  herself,  ft  was  with  great  difficulty  that  she  | 
could  bring  herself  to  take  up  her  own  clothes,  and  only  after  she 
had  vanquished  her  repugnance  to  touch  them  ; but  no  sooner  had  | 
she  got  them  between  her  fingers  than  she  felt  herself  compelled  | 
to  wash,  and  immediately  she  was  dry  she  began  to  wash  again.  | 
It  was  impossible  to  prevent  her  washing  herself,  for  she  would  | 
break  out  into  fury,  thrust  her  hands  into  her  hair,  cry  out,  use  | 
imprecations  against  her  mother,  become  red  in  the  face,  and  perspire  | 
from  anguish  and  fear,  so  that  one  had  to  let  her  do  what  she  wanted.  | 
There  were  very  few  hours  of  peace.  Sufferers  of  this  class  have  a -1 
great  repugnance  to  changing  their  linen  and  their  clothes.  They  i 
put  on  the  same  things  over  and  over  again,  until  they  become  j 
filthy  (contrast).  In  connection  with  the  sense  of  space,  agora-  :| 
phobia,  claustrophobia,  and  acrophobia  are  well  known.  In  all 
these  cases  the  perception  of  the  relations  of  space  is  altered,  giving 
rise  to  the  idea  of  fear,  of  danger,  or  of  destruction,  and  the  anguish  1 
consequent  thereon.  The  sufferer  from  agoraphobia  is  afraid  of  I 
wide  spaces  or  open  squares  in  towns.  As  soon  as  he  enters  a square  , 
he  is  seized  with  extreme  anguish,  cold  perspiration,  and  palpitation. ' 
In  the  most  serious  cases  he  is  sometimes  doubled  up,  and  falls  as  ^ 
though  in  a faint  if  he  be  not  supported.  Should  he  require  to| 
cross  a square  in  the  course  of  his  business  he  would  rather  make  his  <| 
way  round  it,  through  lanes,  or  get  someone  to  accompany  him.  ,j 
He  feels  more  confident  when  on  the  arm  of  a friend,  and  he  faces 
the  risk.  A stick  is  also  a relief  to  him.  The  same  anguish  is  felt 
by  those  who  are  afraid  of  closed  places  (the  claustrophobia  of  Verga) 
every  time  they  are  shut  up  in  a room,  a theatre,  a church,  or  a 
railway  carriage,  as  soon  as  the  door  is  closed  and  the  locomotive 
starts.  In  such  a case  it  is  not  actually  the  fear  of  an  extensive 
space  or  of  a closed  space.  It  is  an  idea  of  fear  that  has  pre-existed 
and  is  reassociated  under  special  conditions  with  the  perception 
of  space.  A gentleman  subject  to  agoraphobia  began  to  suffer  from  , 
it  after  one  of  his  brothers  had  been  seized  by  cerebral  haemorrhage 
in  a city  square.  Every  time  he  entered  a large  square  there  arose 
before  his  mind  the  terrifying  idea  that  he  too  might  be  seized,  and  ' 
might  die  there,  as  had  happened  to  his  brother.  A celebrated 


FIXED  IDEAS  AND  OBSESSIONS 


629 


railway  engineer,  a noted  traveller,  when  setting  out  on  a journey, 
was  seized  by  unbearable  fear  and  anguish  whenever  the  train 
started,  so  much  so  that  he  frequently  indulged  the  thought  of 
opening  the  door  and  throwing  himself  out,  although  such  an 
action  would  have  cost  him  his  life.  This  trouble  commenced 
after  a railway  accident  in  which  he  had  been. 

All  the  perceptions  furnish  material  for  phobias  : Metals  (metallo- 
phobia),  water  (hydrophobia),  glass  (crystallophobia),  velvet,  red, 
blood,  a dead  body,  poison  (iophobia),  needles  (belenophobia), 
precipices  (eremnophobia),  rivers  (potamophobia),  lightning  and 
storms  (astraphobia),  etc. 

On  one  occasion  a Neapolitan  woman  belonging  to  the  lower 
classes  (where  the  use  of  the  knife  is  common)  suffered  a vivid 
impression  on  seeing  a knife  lying  on  the  ground  as  she  passed  along 
a certain  street,  and  from  that  day  forward  she  had  no  longer  any 
peace.  The  image  of  the  knife  could  not  be  dismissed  from  her 
sight,  and,  as  often  happens,  she  was  forced  by  the  law  of  contrast  to 
return  frequently  to  the  spot  where  she  had  first  seen  the  knife,  a 
prey  to  strong  emotion.  She  ceased  to  care  for  her  children,  lost 
her  good  humour,  and  became  irritable,  melancholic,  and  always 
raving.  She  was  aware  of  the  irrationality  of  the  fear  and  the  use- 
lessness of  returning  to  the  place  where  she  had  received  the  impres- 
sion, but  she  could  not  control  herself,  for  she  was  overmastered 
by  a terrible  feeling  of  anguish. 

A boy  of  fourteen  years  old  had  an  extraordinary  fear  of  dolls. 
He  belonged  to  a family  with  grave  hereditary  taint,  and  he  had  not 
got  much  beyond  the  limits  of  the  most  modest  physiological 
intelligence.  The  sight  of  a doll  inspired  him  with  very  great  fear. 
When  he  was  walking  through  the  streets  of  the  city  he  would  leave 
his  friends,  who  were  on  the  pavement,  and  go  along  the  middle 
of  the  street,  lest  he  should  pass  near  shops  with  dolls  in  the  windows. 
I wished  to  be  certain  about  this  very  strange  phobia,  and  I invited 
my  esteemed  colleague,  who  had  presented  this  patient  to  me,  to 
go  into  the  drawing-room  in  my  house,  where  I had  previously  placed 
a big  doll  that  belonged  to  one  of  my  little  girls  on  an  arm-chair. 
I pretended,  according  to  previous  arrangement  with  my  colleague, 
that  I wished  to  show  him  a picture,  and  the  boy  followed  heedlessly 
behind  us.  When  he  got  near  the  chair  he  gave  a cry,  turned  pale, 
and  ran  as  fast  as  he  could  towards  the  balcony  of  the  drawing- 
room, which  we  reached  just  in  time  to  catch  him  and  take  him  back 
to  the  consulting-room,  where  he  remained  a prey  to  the  strongest 
B emotion.  If  I were  fond  of  giving  names  to  phobias  that  have  not 
yet  been  described,  I might  call  this  one  ‘ pediophobia,’  but  it  is  not 
worth  while. 

Morbid  fear  of  illness,  or  pathophobia,  is  very  common.  After 
the  outbreak  of  cholera  in  1884,  it  was  frequent.  Persons  of  serious 
character,  usually  belonging  to  good  society,  are  continually  tor- 


630 


PSYCHIATRY 


merited  by  the  emotional  idea  that  an  epidemic  of  cholera  will  come, 
and  they  look  anxiously  for  some  notice  in  the  newspapers.  They 
do  not  sleep,  and  in  summer  they  go  to  places  that  they  consider 
to  be  most  immune  from  disease.  These  persons  are  really 
obsessed. 

Sometimes  such  irrational  fears  occur  only  on  certain  occasions — 
for  example,  on  seeing  a certain  article,  or  in  certain  particular 
positions.  Phobias  of  this  description  are  very  common.  They 
are  not  quite  so  morbid  as  the  others,  just  because  they  leave  the 
sufferer  in  peace  so  long  as  the  particular  occasion  does  not  occur. 

A man  once  assisted  at  the  slaughter  of  an  ox,  and  the  thought  then 
occurred  to  him  that  he  might  be  put  in  the  place  of  the  ox.  From 
that  time  he  has  been  unable  to  free  himself  from  the  intense  fear 
caused  by  this  recollection,  and  it  becomes  more  acute  every  time 
he  sees  an  ox  or  a slaughter-house,  or  when  he  hears  either  of  those 
words  pronounced. 

History  also  furnishes  us  with  some  examples.  Ladislaus, 
King  of  Poland,  would  run  away  in  terror  at  the  sight  of  apples. 
Henry  III.,  who  showed  so  much  valour  in  many  instances,  could  j 
not  control  his  emotion  of  fear  at  the  sight  of  a cat.  The  Duke  of  | 
Epernon  had  great  fear  of  a young  ape  ; and  so  on  in  many  other  -j 
cases.  Sometimes  these  phobias  have  a professional  character  and  .1 
resemble  professional  dyskinesis,  as  Berillon  has  acutely  observed.  ;| 
I shall  give  some  examples.  :| 

A young  cleric,  who  could  get  through  all  the  other  duties  of  ,, 
the  priesthood,  was  seized  with  real  anguish  whenever  he  entered 
the  pulpit  (Berillon). 

A druggist  suffered  absolute  terror  every  time  he  made  out  a I 
prescription  containing  poison,  as  he  was  afraid  of  poisoning  his  i 
customers.  ^ 

A theatrical  artist,  though  he  had  had  a very  successful  career,  was  j 
forced  to  leave  the  boards  owing  to  the  anguish  with  which  he  was  I 
seized  when  he  had  to  appear  before  the  public.  This  phenomenon  i 
belongs  also  to  timidity,  and  has  been  described  by  Hartenberg,  » 
and  more  recently  by  Francotte.  Sometimes  railwa5’-engine  drivers  ’ 
are  seized  with  strong  anxiety  at  the  mere  sight  of  steam-engines — 
the  ‘ siderodromophobia  ’ of  Riegler. 

A distinguished  Parisian  surgeon  became  a victim  of  insuperable 
anguish  the  moment  a patient  left  his  consulting-room  with  a 
prescription,  from  fear  lest  he  should  have  prescribed  poisonous 
dosesTBcgis  and  Pitres). 

Desires,  like  the  phobias,  are  forms  of  emotion,  and  writers 
have  not  all  ascribed  to  them  the  importance  that  they  merit.  ; 
Desires  represent  the  opposite  pole  to  that  of  fear  and  repulsion.  | 
Phobia  repels  us  from,  but  desire  drives  us,  with  more  or  less  emotion,  ! 
towards  the  object  that  provokes  the  particular  state  of  mind. 
Both  phobia  and  desire  must  pass  through  the  same  gradations, 


FIXED  IDEAS  AND  OBSESSIONS 


•631 


from  the  subtle  vibrations  that  begin  about  the  limits  of  indifference 
to  the  most  destructive  commotion  of  the  mind  when  we  do  not 
succeed  in  escaping  from  what  is  repellent  or  do  not  obtain  what 
pleases  us.  In  states  of  mental  weakness  due  to  heredity  or 
neurasthenia  these  desires,  which  are  irrational  and  almost  always 
for  trivial  or  hurtful  things,  reach  their  maximum  degree,  subju- 
gating the  mind  uncontrollably  and  implacably,  and  forcing  the 
victim  to  those  acts  that  will  satisfy  the  desire.  Within  certain 
limits  the  desires  and  actions  are  known  to  be  irrational,  improper, 
and  hurtful  to  the  patient  himself.  Let  one  example  serve  for  all. 

Some  years  ago  I saw  a lady  who  had  come  along  with  her 
husband,  from  a town  in  Sicily,  for  the  express  purpose  of  consulting 
me.  She  was  a young  married  woman,  belonging  to  a neuropathic 
family,  and  she  presented  unmistakable  signs  of  anthropological 
degeneration  and  mental  weakness.  Previous  to  her  marriage  she 
suffered  for  several  years  from  mysophobia,  from  which  she  had  not 
completely  recovered.  A few  days  after  her  marriage  an  agreeable 
impression  was  made  on  her  by  a certain  crackling  sound  produced 
by  her  husband,  that  sound  making  on  her  the  impression  of  one 
of  the  sweetest  of  conjugal  delights  (perversion,  degeneration). 
From  that  moment  she  was  overmastered  by  the  desire  to  hear  the 
sound  repeated,  and  she  prayed  and  besought  her  husband  to  make 
the  sweet  music  again.  The  poor  husband  was  surprised,  but 
managed  to  satisfy  her  once  more.  The  mania  increased,  how- 
ever ; the  lady  became  agitated,  had  cold  sweats,  and  almost  went 
into  convulsions  if  her  desire  was  not  satisfied.  The  scene  was 
repeated  every  night  when  they  went  to  bed,  and  the  unhappy 
husband  had  to  prepare  himself  as  well  as  he  could  to  satisfy  her 
twice,  or  at  most  three  times.  She,  however,  insisted  on  the  music 
being  ten  times  repeated,  which  was  quite  impossible,  and  so  there 
were  the  usual  outbreaks  of  mania.  The  unfortunate  woman  told 
me  this  story  in  tears,  and  besought  me  in  charity  to  free  her  from 
this  strange  desire,  because  on  the  one  hand  she  felt  herself  humili- 
ated by  it,  and  on  the  other  she  suffered  unbearable  anguish  when 
she  was  not  satisfied. 

As  will  be  observed,  desires  may  be  of  the  most  diverse  and 
extraordinary  character,  and  there  is  no  need  to  trouble  ourselves 
about  the  names  to  be  given  to  manifestations  of  this  sort.  There  is, 
however,  one  category  of  cases  that  has  been  very  thoroughly  studied, 
though  not  classed  by  all  authorities  amongst  obsessions.  These 
cases  comprise  certain  degenerates,  congenitally  neuropathic,  or  who 
have  become  neuropathic  through  the  circumstances  of  their  lives, 
who  exhibit  an  invincible  desire  for  alcoholic  substances  or  drugs, 
after  they  have  once  derived  some  advantage,  or  even  some  transient 
relief,  from  their  use.  Here  I refer  to  dipsomania,  cocainomania, 
morphinomania,  chloralomania,  zincomania,  antipirinomania,  and  all 
the  other  manias  now  met  with,  or  that  will  be  met  with  in  future, 


632 


PSYCHIATRY 


as  pharmacology  advances.  Individuals  affected  by  these  are  for 
the  most  part  weak  ; they  feel  worn  out,  and  in  addition  to  their 
asthenia  they  suffer  from  a real  malady  of  the  kinaesthetic  sense, 
which  manifests  itself  in  undefined  suffering,  localized  in  most  cases 
in  the  stomach  (cardialgia),  or  in  the  head  (cephalalgia).  As  they 
cannot  tolerate  trouble  or  pain,  they  have  recourse  to  some  calmative 
or  hypnotic,  which  to  begin  with  is  generally  prescribed  by  their 
medical  attendant. 

When  the  remedy,  as  frequently  happens,  gives  them  relief 
or  a ceitain  degree  of  well-being  and  vigour,  it  becomes  their 
inseparable  friend,  the  comforter  of  their  existence,  a deity  to  whom 
incense  is  offered  by  the  enslaved  mind.  They  cannot  give  up  the 
drug  ; they  carry  it  with  them  when  travelling  or  when  out  walking  ; 
it  takes  the  first  place  among  the  ‘ necessities  ’ of  their  existence  ; 
they  cannot  live  without  it.  The  desire  cannot  be  overcome  by  any 
reasoning,  by  any  exhortation,  or  by  any  effort  of  will. 

From  time  to  time  the  dipsomaniac  is  seized  by  a certain  feeling 
of  discomfort,  which  soon  becomes  associated  with  the  idea  of 
drinking  wine  or  liqueur,  for  the  reason  that,  on  a former  occasion, 
a small  quantity  of  wine  or  liqueur  was  useful  in  restoring  him  or 
giving  him  a feeling  of  comfort.  The  subject  is  often  the  son  of  an 
alcoholist,  and,  as  happens  to  all  weak  and  psychopathic  persons, 
the  psychic  product  of  an  association  becomes  fixed.  The  dis- 
comfort increases  with  the  desire  to  drink,  and  the  subject  struggles 
as  best  he  can  against  this  obsession  ; but  he  soon  yields,  and 
drinks  his  first  glass  of  wine,  or,  if  it  is  in  the  morning,  his  first  glass 
of  liqueur.  From  that  moment  the  mania  for  drinking  becomes 
all-powerful,  the  thirst  ardent,  and  the  obsession  imperative.  He 
buys  bottles  of  liquors,  or  goes  round  the  shops  sipping  them. 
The  more  the  conscience  is  obscured  the  more  the  power  of  resistance 
is  diminished.  He  no  longer  eats — he  simply  drinks.  He  suffers 
from  burning  thirst,  hre  in  the  head,  and  staggering  ; he  vomits, 
and  drinks  again.  Finally,  he  falls  into  a comatose  state,  and  is 
picked  up  on  the  roadside  ; or,  having  profited  by  experience,  he 
gets  into  this  condition  shut  up  in  his  house,  where  he  has  previously 
laid  in  a store.  When  he  comes  to  himself  he  is  weak  and  worn  out, 
confused  and  melancholy.  He  has  headache  and  is  sleepy.  Slowly 
he  returns  to  his  normal  condition,  and  then  he  either  loathes  wine 
and  liqueur  for  a certain  time  or  uses  them  in  moderation  until  he 
has  another  outburst.  The  same  thing  happens  to  the  morphinists, 
mutatis  mutandis. 

The  punctures  of  Pravaz’s  S3U'inges,  the  little  abscesses  and  the 
sores  that  these  sometimes  produce,  the  offences  to  the  aesthetic 
sense  tliat  young  women  sometimes  commit  by  disfiguring  the  fair 
skin  of  the  abdomen  and  the  thighs  with  cicatricial  dark  nodules, 
are  mere  trifles  for  them,  as  are  also  their  paleness  and  loss  of  flesh. 
l:.\'erytlnng  is  sacrificed  to  their  god — morphine,  cocaine,  or  opium. 


633 


FIXED  IDEAS  AND  OBSESSIONS 

All  these  subjects  are  aware  of  the  harm  that  they  aie  doing 
themselves,  and  of  the  injury  to  their  health.  They  would  like  to 
emancipate  themselves  from  the  tyranny  of  this  strange  master, 
but  the  desire  is  much  more  powerful  than  their  wills,  and  so  the 
struggle  is  useless.  Morphinists,  chloralists,  and  cocainists  are  all 
the  same  : they  are  obsessed,  like  the  victims  of  phobias  and  the 
dipsomaniacs  ; the  only  difference  is  in  the  content  of  the  emotion 
that  obsesses  them. 

We  come  now  to  describe  another  group  of  obsessions  the 
obsessive  impulses. 

There  are  ideas  which  have  a motor  content,  which  present  them- 
selves before  the  consciousness,  and,  either  directly  or  through 
the  law  of  contrast,  exert  irresistible  power  of  translating  themselves 
into  action.  These  are  the  so-called  impulsive  ideas  ; they  aie 
the  reflex  of  identical  percepts,  or  they  arise  through  contrast. 
Once  they  have  reached  the  field  of  consciousness  these  percepts 
fix  themselves  there,  in  open  contrast  with  the  sentiments  and  the 
tendencies  of  the  subject. 

A lady  heard  a tale  of  a woman  who,  in  a fit  of  anger,  lesulting 
from  a quarrel,  had  put  out  another  woman’s  eye.  She  had  along 
with  her  her  only  daughter,  a little  girl  of  seven  years  old,  whom 
she  loved  excessively,  and  under  the  emotion  of  the  terrible  story 
she  thought,  ‘ If  I were  to  scoop  out  one  of  my  daughter’s  eyes !’ 
A shudder  passed  through  her,  she  shook  with  horror,  seized  the 
child’s  head  in  her  convulsive  hands,  and  kissed  it  over  and  ovei 
again,  almost  weeping  ; but  suddenly  she  pushed  her  far  away , for 
the  image  of  the  deed,  the  motor  intuition,  the  imperative  tendency 
to  realize  it  against  every  effort  of  her  will,  fixed  themselves  like 
thorns  in  her  mind.  She  became  melancholic,  lost  her  appetite, 
consulted  doctors,  and  was  driven  to  despair  by  the  tyranny  of  the 
frightful  obsession.  She  became  afraid  of  all  sharp  instruments, 
especially  of  scissors,  with  which  she  could  most  easily  have  obeyed 
the  obsession.  It  was  necessary  to  have  the  daughter  taken  away 
from  her,  as  the  mother  could  not  be  removed  for  family  reasons. 
She  recovered  after  six  months. 

At  other  times  ideas  arise  spontaneously,  as  if  through  the 
victory  of  feelings  or  ideas  of  contrast. 

Here  is  an  example  : 

A cultured,  intelligent,  but  hysterical  lady,  without  children  of 
her  own,  had  living  with  her  an  infant  daughter  of  one  of  her  sisters, 
and  she  loved  the  child  tenderly.  One  day  she  was  looking  over 
the  balcony  of  a room  on  the  third  floor,  holding  the  baby  in  her 
arms  and  caressing  it.  Suddenly  a grotesque  and  insidious  thought 
flashed  through  her  mind  : ‘ If  I were  to  throw  it  down  !’  She  went 
back  again  into  the  room,  a prey  to  the  strongest  emotion.  She 
clasped  the  child  firmly  in  her  arms,  wept,  trembled,  and  was  in 
despair  that  she  should  ever  have  thought  of  such  an  action  so 


634  PSYCHIATRY 

entirely  opposed  to  the  lively  and  sincere  affection  that  she  had  for 
her  little  guest.  From  that  day  on,  however,  the  impulsive  thought 
was  rooted  in  her  consciousness,  seated  there  as  on  a throne,  tor- 
mienting  her,  scourging  her,  and  dominating  her  mind.  The  lady 
became  sleepless,  pale,  and  irritable.  She  ceased  to  look  after  her 
household.  Several  times  she  came  to  consult  me,  a prey  to  the 
most  extreme  anguish.  She  recovered  about  a year  later,  after  the 
child  had  been  removed,  and  she  herself  had  been  sent  away  to 
quite  different  surroundings. 

In  this  same  class  we  must  enumerate  the  obsessions  of  suicide 
and  of  homicide. 

We  know  the  psychological  mechanism  of  suicide  in  melancholia 
and  in  the  various  insanities — epilepsy,  paranoia,  neurasthenia, 
etc.  Obsession  is  quite  another  matter.  The  idea  of  suicide  arises 
and  surrounds  itself  with  a cortege  of  motor  intuitions  that  press 
upon  the  consciousness,  which  defends  itself  but  weakly.  In  these 
cases  melancholia  is  consecutive  to,  and  dependent  upon,  the 
keenness  of  the  struggle,  the  fear  of  succumbing,  and  the  imminent 
danger  that  the  impulse  will  be  translated  into  action  (Wille, 
Legrand  de  Saulle). 

The  obsession  of  homicide  has  the  same  characteristics.  One 
example  will  suffice.  One  day  there  came  to  my  private  con- 
sulting-room a tall,  pale,  thin  man,  with  black  and  catlike  eyes,  and 
aquiline  nose.  Altogether  he  presented  a somewhat  savage  and 
grotesque  figure.  When  asked  to  sit  down  and  tell  me  the  story  of 
his  sufferings,  he  placed  himself  very  close  to  me,  and  said,  ‘ Professor 
I shall  be  brief.  For  three  years  past  I have  had  no  peace.  A 
terrible  thought,  from  which  I have  been  quite  unable  to  free  myself, 
is  crucifying  my  spirit  and  terrifying  me  ; it  is  a fixed  idea  of 
wounding,  of  killing  somebody,  that  gives  me  much  pleasure,  yet 
causes  me  great  terror.  I cannot  sleep,  I cannot  eat,  I cannot 
work  ; I have  no  interest  in  anything,  and  I hate  my  life.  I 
struggle  in  vain,  and  I am  afraid  that,  in  a weak  moment,  I shall 
compromise  myself  and  the  honour  of  my  family.’  As  he  spoke 
these  words  he  was  constantly  becoming  more  excited,  whilst  almost 
a shudder  ran  through  his  body  ; his  eyes  flashed,  and  he  came 
closer  and  closer  to  me,  so  that  I had  very  cautiously  to  assume  a 
position  of  defence. 

In  this  subgroup  are  comprised  obsessive  pyromania  and  klepto- 
mania. In  obsessions  of  this  sort  we  have  neither  imbecility,  nor 
the  unconsciousness  of  the  epileptic,  nor  the  deliberate  design  of  a 
delinquent  ; there  is  only  the  imperative  obsession  that  constantly 
forces  the  subject  to  do  a deed  that  is  in  the  highest  degree  repug- 
nant to  him.  A surgeon-captain  in  the  navy,  neuropathic  and  a 
misanthrope,  in  whose  case  I had  to  express  an  opinion  in  the 
course  of  judicial  proceedings,  was  obsessed  by  the  notion  of  stealing 
sugar  and  coffee  from  one  of  his  messmates  whenever  he  had  the 


FIXED  IDEAS  AND  OBSESSIONS 


635 


opportunity,  although  theft  was  repugnant  to  him,  and  although 
he  knew  he  could  not  make  use  of  what  he  had  stolen,  for  he  was  in 
easy  circumstances,  and  hardly  ever  took  coffee.  It  was  an  impera- 
tive impulse  that  he  could  not  resist. 

When  obsessive  impulses  are  harmless  they  are  rapidly  put  into 
action,  and  we  find  hardly  any  trace  of  a struggle,  except  the 
anguish  that  arises  from  the  extrinsic  difficulties  met  with  in  per- 
forming the  act. 

One  has  the  obsession  of  counting  all  the  windows  in  a palace  as 
he  passes  along  the  street  (an  obsession  from  which  Napoleon  I. 
appears  to  have  suffered).  Another  counts  all  the  lamps  in  the  street 
every  time  he  passes  along  it,  and  if  he  makes  a mistake  he  falls 
into  a state  of  anguish,  turns  back,  and  counts  them  over  again. 
Another  is  forced  to  count  the  books  arranged  in  a library  ; still 
another  will  count  the  letters  in  one  or  several  words,  or  will  make 
interminable  calculations  (arithmomania).  x^nother  person  is  forced 
to  make  calculations  always  with  odd  numbers.  A man  writing  a 
book  labours  to  fix  the  number  of  the  pages.  One  of  my  patients 
felt  himself  forced  to  measure  the  length  and  breadth  of  the  Piazza 
Dante  every  time  he  passed  through  it,  and  after  doing  this  he  was 
tormented  by  a doubt  that  he  had  not  measured  it  correctly,  and 
that  the  number  of  paces  that  he  had  found  was  not  the  exact 
number.  Others  yield  to  the  obsession  to  pronounce  certain  words, 
most  frequently  obscene  or  ridiculous,  even  when  they  are  talking 
face  to  face  with  another  person. 

To  this  obsession,  which  often  becomes  automatic,  the  name 
of  coprolalia  has  been  given.  In  course  of  time  it  becomes  a tic. 

The  more  frivolous  obsessions,  those  which  do  not  come  into 
conflict  with  the  moral  sentiments,  become  automatic  acts,  and 
then  the  obsession  ceases.  To  this  category  belong  musical  obses- 
sions (De  Sanctis).  There  are  individuals  who,  once  they  have 
heard  a passage  of  music  or  a melody,  hear  it  repeated  in  their  ears 
an  endless  number  of  times.  This  music  becomes  an  actual  torment, 
and  sometimes  the  subjects  are  obliged  to  sing  the  air  over  and  over 
again.  Nothing  will  enable  them  to  forget  it  or  to  restrain  their 
impulse  to  sing. 

Sometimes  the  motor  impulse  is  discharged  from  the  automatic 
centres,  for  which  the  inhibiting  power  of  the  superior  centres  is 
insufficient.  Such  a case  we  have  in  the  tendency  to  laugh  in 
presence  of  ever}^  person.  A young  employe,  highly  educated 
and  intelligent,  was  tempted  to  laugh,  and  did  laugh,  every  time  he 
met  anyone  he  knew.  At  first  the  phenomenon  was  restricted  to  his 
relations  with  his  office  companions,  but  afterwards  its  range  was 
exXtended.  Several  times  he  ran  the  risk  of  compromising  himself. 
He  deplored  the  fact,  fell  into  a state  of  anguish,  and  was  afraid  of 
meeting  people  in  case  he  should  laugh  in  their  faces. 

Motor  impulse  is  also  characteristic  of  the  ereutophobia  described 


636 


PSYCHIATRY 


by  Regis  and  Pitres,  and  termed  the  ‘ obsession  of  blushing  ’ by 
Soury.  The  following  is  a summary  of  the  important  article  pub- 
lished by  those  authors  in  the  Archives  de  Nevrologie,  1897.  A 
neuropathic  youth  blushes  under  given  circumstances,  and  a 
painful  impression  follows.  From  that  moment,  under  the  same 
circumstances  and  in  the  presence  of  persons,  the  emotive  blushing 
is  reproduced,  with  moral  pain,  and  the  subject  is  preoccupied  with 
it.  Up  to  this  point  the  phenomenon  has  been  intermittent  and 
occasional,  but  gradually  the  thought  of  this  infirmity  invades  the 
mind,  dominates  it,  makes  it  restless,  and,  to  make  matters  worse, 
all  recollection  of,  or  preoccupation  with,  blushing  causes  further 
blushing,  so  that  the  poor  patient  is  continually  dominated  by 
this  emotional  phenomenon.  ‘ The  phobia  becomes  an  obsession,’ 
in  which  the  motor  impulse  is  discharged  along  the  vaso-dilator 
nerves.  No  obsession  is  so  humiliating  or  causes  so  much  fear  as 
this  one.  No  victim  of  obsession  is  more  given  to  the  idea  of 
suicide  than  the  ereutophobiac.  Such  persons  feel  the  heat  in  the 
face,  and  are  conscious  of  their  blushing,  so  that  they  have  no  tran- 
quillity even  in  the  midst  of  their  families,  at  their  employments,  or 
on  the  streets.  It  seems  to  them  that  their  blushing  is  a constant 
accusation  of  something  that  they  have  done.  Some  of  them  shut 
themselves  up  at  home,  and  do  not  leave  the  house  except  at  night, 
for  night  gives  them  the  tranquillity  that  dawn  deprives  them  of. 

Of  the  same  nature  is  the  fear  of  requiring  to  evacuate  the  bowels 
when  away  from  the  house,  and  particularly  when  visiting  other 
people,  or  in  the  theatre  or  the  church.  The  fear  that  such  a thing 
will  occur  produces  the  dreaded  result  ; the  intestines  are  set  in 
motion  on  all  occasions  of  the  sort,  and  the  discharge  of  the  bowels, 
present  from  the  first  as  a kinsesthetic  image,  is  irresistibly  pro- 
duced. The  recollection  of  this  fact  and  the  fear  of  its  repetition 
are  continually  represented,  until  they  assume  the  character  of  an 
obsession. 

This  might  be  termed  ‘ coprophobia.’  I have  observed  it  only 
twice,  in  the  persons  of  adult  women. 

There  are  other  obsessions  which  do  not  exceed  the  limits  of 
sanity.  Among  these  I might  mention  onomatomania,  which  is 
comparatively  frequent  (Charcot  and  Magnan).  This  is  the  painful 
search  for  a name  or  a word,  with  or  without  an  irresistible  impulse 
to  repeat  it  when  found.  On  most  occasions  the  anguish  is  due 
to  the  fear  of  not  finding  it,  and  might  be  called  ‘ amnesiphobia.’  It 
occurs  also  to  sane  persons  that  they  cannot  recall,  with  the  requisite 
promptitude,  some  particular  name  or  other,  which,  however, 
recurs  to  the  mind  some  time  afterwards,  either  spontaneously 
(unconscious  cerebration)  or  as  the  result  of  reflective  concentration 
of  the  will.  In  such  a case  the  consciousness  is  usually  slightly 
troubled  until  the  name  or  the  word  is  remembered.  In  cases  of 
obsession,  however,  tlie  anguish  is  intense,  and  the  mind  is  concen- 


FIXED  IDEAS  AND  OBSESSIONS 


637 


trated  upon  the  word  that  will  not  come  up.  Even  when  it  has  been 
evoked,  the  fear  of  not  being  able  to  remember  it  or  some  other 
word,  continues,  and  the  subject  passes  many  hours  of  the  day 
in  evoking  the  words,  being  troubled  by  the  thought  that  he  will 
be  unable  to  summon  them  when  necessary.  This  occurs  more 
rarely  in  the  recollection  of  passages  of  prose  or  pieces  of  poetry. 

One  of  my  patients  had,  among  other  obsessions,  that  of  testing 
his  memory  by  repeating  a canto  of  Dante  or  a poem  of  Leopardi, 
and  this  caused  him  days  of  anguish. 

Sometimes  questions  of  philosophy  plant  themselves  in  the 
consciousness  as  a perennial  interrogation.  ‘ How  was  the  world 
created  ?’  ‘ Does  a God  exist  ?’  ‘If  so,  how  and  by  whom  was 

He  created  ?’ 

These  questions  are  like  an  oyster  fixed  on  a rock  emerging 
from  the  sea,  and  opening  its  valves  every  now  and  again  for 
nutriment.  Though  so  many  waves,  both  gentle  and  raging,  dash 
around  it,  they  cannot  detach  it. 

A learned  philosopher,  the  story  of  whose  malady  has  been 
referred  to  by  Regis  and  Pitres,  wrote  the  following,  among  other 
matters,  to  the  author  of  the  report  : ‘ To  read  in  the  newspapers 
that  Kaiser  William  or  the  President  of  the  Republic  had  to  smile 
500  or  1,000  times  during  a reception  sometimes  causes  me  real 
anguish.  I could  far  more  easily  perform  the  labours  of  Hercules 
than  do  that.’  Meanwhile  this  thought  had  become  a true  obsession, 
so  that  he  ultimately  wrote  that  he  was  resigned  to  carry  his  malady 
to  the  grave. 

In  one  group  of  cases,  not  at  all  rare,  the  obsessive  ideas  are 
of  aesthetic  and  hypochondriacal  content.  A young  lady  who  had 
the  good  fortune  to  have  a rich  and  beautiful  head  of  blonde  hair 
conceived  the  idea,  in  consequence  of  strange  sensations  in  the 
scalp,  that  her  hair  had  fallen  out,  and  that  the  portion  that 
remained  had  become  stiff  as  bristles.  This  notion,  of  which  she 
made  every  effort  to  rid  herself,  was  the  constant  affliction  of  her 
whole  youth.  She  would  weep  and  fall  into  despair,  eat  very  little, 
and  often  stay  indoors  for  weeks  at  a time.  I saw  her  after  she 
had  suffered  from  the  malady  for  several  years,  and  sometimes  she 
would  ask  me  if  it  was  not  true  that  her  hair  had  been  changed 
to  bristles  (rudimentary  paranoia).  Another  very  beautiful  lady, 
whose  cherry  lips  were  surmounted  by  a fine  down  that  looked  almost 
like  a voluptuous  veil  over  the  upper  lip,  had  been  tormented  for 
years  by  the  obsession  that  that  down,  which  was  nothing  more  than 
what  every  brunette  has,  w^ould  grow  like  a moustache.  She  passed 
the  greater  part  of  the  day  before  her  mirror.  She  was  constantly 
asking  the  inmates  of  her  house  as  to  the  condition  of  the  hair  on 
her  upper  lip,  while  long  fits  of  anguish  alternated  with  short 
periods  of  calm.  She  obliged  her  husband  to  bring  her  from  a 
distant  province  to  consult  me.  Two  years  later  she  recovered. 


638 


PSYCHIATRY 


From  this  brief  outline  it  will  be  inferred  that  the  phobias  and 
obsessions  are  almost  always  the  product  of  percepts  that  impinge 
upon  a morbid  emotive  basis. 

The  importance  of  emotions  produced  by  percepts,  as  the 
element  determining  the  obsession,  is  proved  by  a great  number 
of  observations,  from  which  I select  the  following  one  : 

As  a man  of  forty-three  years  was  returning  home  from  a place 
at  some  considerable  distance  night  overtook  him,  and  he  lost 
his  way.  He  wandered  about  the  country,  a prey  to  vivid  and 
strong  emotions,  and  almost  went  crazy  with  fear,  so  much  so 
that  he  did  not  hear  the  voices  of  those  who  were  calling  him  by 
name.  From  that  day  he  had  an  absolute  fear  of  the  country, 
and  an  invincible  and  irrational  desire  for  his  own  house.  When- 
ever he  went  the  slightest  distance  from  home  he  was  overcome  by 
strong  agitation,  felt  as  though  some  obstacle  might  prevent  him 
from  returning,  and  was  seized  by  an  irresistible  desire  to  reach 
home  again.  If  he  were  prevented  he  suffered  from  anguish,  cold 
sweats,  and  accessions  of  fear.  He  recognised  the  irrationality  of 
these,  and  tried  to  free  himself  from  them,  but  in  vain. 

Breuer,  Freud,  and  Janet,  especially  the  last,  describe  the 
so-called  ‘ subconscious  fixed  ideas.’  These  ideas,  which  may 
have  serious  consequences,  are  represented  and  maintained  only 
during  hysterical  attacks,  dreams,  and  somnambulism.  In  the 
normal  state  they  remain  outside  the  consciousness.  I have  said 
ideas,  but  they  may  be  judgments,  fears,  or  impulses.  One  of 
Janet’s  hysterical  subjects  used  to  repeat  during  eveiy  accession, 

‘ My  husband,  my  poor  children,  that  poor  Jeanne,  who ’ 

Occasionally  we  get  hallucinations  which  are  repeated,  and  are  the 
reflection  of  a terrifying  event  that  had  occurred  some  time  before. 

I shall  not  dwell  too  long  on  these  phenomena,  which  have  so 
many  analogues  in  normal  life,  as  well  as  in  other  pathological 
states,  and  which,  in  my  opinion,  would  be  wrongly  placed 
among  the  fixed  ideas.  Having  determined  the  limits  of  fixed 
ideas,  and  that  in  no  artificial  way,  and  having  admitted  contrast 
and  emotive  states  of  the  consciousness  to  be  the  characteristic 
features,  I find  insuperable  difiiculties  in  agreeing  with  Janet’s 
views,  which  would  lead  to  confusion  in  the  recognition  of  the 
clinical  figure  of  the  malady  of  fixed  ideas.  These  represent  a 
malady  of  the  consciousness,  while  the  others  are  a malady  of  ‘ the 
unconscious,’  which  opens  a vast  field  to  research  and  to  hypothesis. 
At  the  utmost  these  subconscious  fixed  ideas  form  a zone  inter- 
mediate between  true  obsessions  and  hysteria. 

To  return  to  obsessions  after  this  slight  digression,  I shall  touch 
slightly  upon  some  other  particular  points.  Among  these  the 
character  of  certain  phobias  must  be  noted.  Morselli  has  well 
distinguished  fixed  ideas  into  the  egoistic  and  the  altruistic.  I 
cite  only  a few  examples. 


FIXED  IDEAS  AND  OBSESSIONS 


639 


A good  girl  is  afraid  of  pronouncing  or  having  pronounced 
words  that  are  disrespectful  to  persons  whom  she  knows,  loves, 
and  esteems.  A boy  of  nine  or  ten  years  of  age  is  careful  not  to 
pass  near  a table  on  which  are  books  or  near  a bookshelf,  owing  to  a 
fear,  which  he  clearly  sees  to  be  irrational  and  morbid,  that  the 
books  will  fall  upon  him,  although  the  table  is  quite  firm  or  the 
bookshelf  properly  balanced.  His  fear  is  much  more  intense  when 
another  person  approaches  a bookshelf  or  a table  on  which  books 
are  lying. 

A ^muth  is  afraid  of  touching  anything,  of  making  himself  dirty, 
or  of  contracting  infection,  not  on  his  own  account,  but  lest  he 
should  dirty  or  infect  other  people.  He  never  gives  his  hand,  not 
because  he  is  afraid  of  soiling  himself,  but  because  he  does  not  wish 
to  soil  or  to  cause  injury  to  others. 

Fixed  ideas  are  very  rarely  accompanied  by  hallucinations. 
This  fact  was  denied  by  Morel,  but  J.  Falret  insisted  upon  it  at  the 
International  Congress  held  in  1889.  In  the  main  it  must  be 
considered  true,  if  we  remember  that  psychiatrists  of  long  and 
extensive  practice  have  never  observed  cases  of  fixed  ideas  asso- 
ciated with  hallucinations.  Cases  are  reported,  however,  which,  if 
they  form  an  exception,  prevent  the  absence  of  sensory  disorders 
from  being  regarded  as  a law.  Tamburini,  Stefani,  Seglas,  Catsaras, 
Mirto,  Fere,  Wernicke,  Pitres,  and  Regis  have  observed  and  pub- 
lished some  cases  of  this  sort.  One  of  my  patients  is  affected  with 
grave  mysophobia  relating  to  milk  and  butter  : every  now  and  again 
he  looks  at  the  tips  of  his  fingers,  even  in  my  presence,  and  notwith- 
standing the  strong  suggestions  that  he  gets  from  me,  and  imagines 
he  finds  there  white  marks  of  milk  or  butter  ; he  is  then  seized  with 
strong  emotion,  and  runs  away  to  wash.  Often  while  he  is  speaking 
he  will  suddenly  bend  down  towards  the  floor,  and  point  with  his 
finger  to  a white  spot,  calling  anxiously  for  his  servant  to  come 
and  wash  away  the  white  speck  that  does  not  exist.  When  he  is 
alone  he  will  pass  hour  after  hour  stooping  to  the  floor  to  look  for 
white  or  yellow  spots,  which  he  sometimes  finds  (hallucinations). 
He  then  runs  to  wash,  and  returns  eagerly  to  the  search,  crying  out 
and  becoming  frantic  in  his  dread  that  similar  substances  may  be 
found  in  his  own  room. 

In  this  case  the  hallucinations  are  simply  the  peripheral  projec- 
tions of  the  phobic  content,  or  of  what  is  closely  connected  with  it. 
The  white  or  the  yellow  is  representative  of  milk  or  butter  in  the 
case  of  my  patient,  and  there  is  corresponding  representation  in 
the  erected  penis  seen  by  the  lady  who  had  a horror  of  sperm. 
This  last  case  is  mentioned  by  Fere. 

It  is  not  difficult  to  believe  that  the  terrible  doubt  that  torments 
those  who  fear  that  they  have  spoken  words  offensive  to  the  Deity 
depends  upon  subconscious  verbal  hallucinations — the  obsessive 
hallucinations  of  the  French. 


640 


PSYCHIATRY 


Visual  hallucinations  are  much  more  frequent  in  morphine- 
maniacs.  Their  presence  generally  denotes  greater  severity  of  the 
malady. 

I have  mentioned  the  reasons  for  which  I hold  that  we  must  not 
confuse  the  fixed  idea  with  systematized  delirium,  and  the  essential 
differences  between  the  two.  I accordingly  think  that  the  title 
of  paranoia  is  very  unsuitable  as  a denomination  for  the  former 
condition,  for  it  includes  the  idea  of  substantial  transformation  of 
the  personality.  There  is,  of  course,  the  possibility  that  the  fixed 
idea  will  become  a delirious  idea,  and  the  nucleus  of  a system  of 
phobias  with  false  judgments.  In  such  a case  the  patient  believes 
in  the  rationality  of  the  fear  and  ceases  his  resistance,  so  that  a 
subdelirious  system  is  organized.  Although  the  pathological 
concept  of  the  fixed  idea  or  of  the  obsession  is  founded  on  the 
contrast  in  consciousness,  I must  still  admit  that  Meynert,  Kraepelin, 
Morselli,  Krafft-Ebing,  and  even  Schfile  himself,  were  not  wrong  in 
ascribing  importance  to  the  paranoic  character  of  the  fixed  ideas, 
because,  as  a matter  of  fact,  in  many  cases  during  the  obsessive 
attack  the  patient  fails  entirely  to  recognise  the  irrationality  of 
his  fear,  and  therefore  of  his  behaviour.  It  is  during  the  intervals 
of  respite  that  he  sees  with  profound  sadness  that  he  has  been  the 
victim  of  obsessions  which  he  recognises  to  be  irrational ; in  some 
cases,  again,  the  obsessive  idea  at  lengtE  assumes  the  character  of 
delirium. 

I give  here  a general  outline  of  a case  which  is  very  interesting 
in  this  respect. 

A young  man  of  high  social  standing,  but  gravely  affected  with 
hereditary  taint,  began  to  be  subject  to  obsessions  when  he  was 
twenty  years  old.  He  experienced  a strong  feeling  of  repugnance 
and  horror  on  finding  a spot  of  oil  on  some  papers  which  he  had  to 
consult,  and  which  were  lying  on  a table.  Thenceforth  he  had  a 
real  horror  of  grease,  and  he  avoided  touching  anything  at  all,  as 
far  as  was  possible,  for  fear  he  should  be  spotted  with  grease.  He 
had  the  soiled  papers  expressly  shut  up  in  a room,  for  fear  lest 
others  might  touch  them  and  involuntarily  carry  grease  to  other 
papers  or  books,  for  in  his  view  that  would  have  been  a serious 
misfortune.  Some  years  later  his  irrational  fear  extended  to  butter, 
from  analogy  with  the  oil  that  had  produced  the  original  spots. 
From  butter  the  obsession  extended  to  milk,  and  soon  after- 
wards also  to  the  animals  that  give  milk — the  goat  and  the  cow. 

He  suffered  extreme  anguish  whenever  cows  or  goats  passed  b}^ 
his  house.  If  he  saw  a cow  pass  along  any  road,  he  would  not  go 
along  that  road  for  months  afterwards.  He  would  also  shut  him- 
self up  in  his  house  to  avoid  stepping  on  ground  over  which  he  knew 
that  a goat  had  trodden.  From  the  outset  he  was  perfectly  aware 
that  his  emotions  were  irrational,  and  he  discussed  his  anguish  with 
me  at  great  length.  Still,  he  was  so  subject  to  them  that  nothing 


FIXED  IDEAS  AND  OBSESSIONS 


641 


would  restore  his  calm  and  give  him  the  freedom  to  go  about  his 
business  that  he  felt  he  urgently  required.  From  fear  of  soiling 
himself  with  grease  he  has  for  years  past  written  nothing  else  than 
telegrams,  on  which  he  spends  a very  large  sum  annually,  and  for 
some  time  back  he  has  not  even  written  these,  but  dictates  them. 

He  is  now  over  fifty-six  years  of  age.  I saw  him  for  the  first  time 
in  1888,  then  I lost  sight  of  him,  but  saw  him  again  in  1892,  since 
when  I have  visited  him  rather  frequently.  The  circle  of  obses- 
sions has  widened  and  extended.  Many  white  articles,  and  especially  . 
slaked  lime,  which  so  much  resembles  milk,  cause  him  great ^ 
torment. 

The  phobia,  or  the  obsession  with  fear,  amounting  to  anguish, 
has  gone  so  far  that  he  will  thrust  his  hands  into  his  hair  and  emit 
painful  or  furious  cries  when  words  resembling  ‘burro’  (butter), 
such  as  ‘pure’  (also),  or  ‘ muro  ’ (wall),  are  pronounced  in  con- 
versation (obsession  progressing  through  alliteration). 

The  important  fact  that  has  induced  me  to  enter  into  these 
details  is  that,  although  the  subject  has  been  aware  of  the  irra- 
tionality of  his  obsessions  for  many  years,  has  consulted  medical 
men  about  them,  and  has  also  fought  against  them  with  all  the 
resources  of  his  intelligence,  which  is  by  no  means  ordinary,  and 
notwithstanding  all  his  wide  culture,  and  all  the  education  he  has 
received  in  surroundings  of  a high  order,  his  struggle  has  become 
gradually  weaker  and  weaker  of  late  years.  ^ 

He  now  actually  believes  that  milk  and  grease  can  penetrate 
a great  distance,  and  cause  great  damage  to  papers,  books,  and 
persons.  He  will  maintain  his  thesis  for  hours,  debating  the 
question  with  an  inexhaustible  wealth  of  strange  arguments  that 
his  mind  has  always  ready.  He  is  convinced  that  milk  can  soil 
him  even  from  a distance  of  33  feet.  In  this  case  it  is  not  only 
the  fear  of  milk  that  tortures  him,  but  the  conviction  that  milk  at 
a distance  has  actually  soiled  him.  It  is  not  now  simply  a question 
of  fears,  the  irrationality  of  which  he  recognises,  but  of  false  judg- 
ments and  absurd  conclusions,  in  defiance  of  all  physical  laws,^ 
which  laws  he  considers  of  no  value,  just  as  paranoiacs  do.  What 
has  happened  to  this  patient  is  what  occurs  in  the  case  of  races  who 
have  been  subjugated  by  a conqueror,  against  whom  they  have  con- 
spired for  many  years,  displaying  for  a long  time  a hostile  attitude, 
and  bearing  his  yoke  always  in  a spirit  of  rebellion.  After  a long 
period  of  more  or  less  tyrannical  government,  when  they  have  been 
disarmed,  reduced  to  misery,  and  their  life-blood  exhausted,  they 
lay  aside  their  enmity,  conform  to  the  will  and  the  laws  of  their 
master,  are  penetrated  by  his  spirit,  character,  and  tendencies,  and 
become  one  with  his  own  people. 

After  thirty  years  the  fixed  idea  has  monopolized  the  conscious- 
ness of  this  most  unhappy  man,  and  has  become  a rudimentary  ^ 
paranoia,  notwithstanding  his  long  resistance.  I agree  with  Morselli 

41 


642 


PSYCHIATRY 


in  giving  the  name  of  obsessive  rudimentary  paranoia  to  this  form 
or  to  these  phases  of  obsession. 

A profound  study  has  now  been  made  of  many  forms  of  inver- 
sion or  perversion  of  the  sexual  instinct,  but  none  of  these  belong 
to  the  category  of  fixed  ideas. 

/Etiology. — In  one  group  of  cases  the  setiological  factor  is  grave 
psychopathic  heredity  while  in  another  group  it  is  the  same  as 
in  neurasthenia. 

Prognosis. — We  distinguish  two  categories  of  cases — those  of 
developmental  psychasthenia  due  to  grave  cerebral  maladies  of 
infancy  or  to  heredity,  in  which  cases  the  disease  appears  very 
early,  sometimes  in  the  beginning  of  childhood,  and  the  cases  of 
acquired  neurasthenia  resulting  from  unfavourable  circumstances 
of  life.  In  the  first  the  prognosis  is  grave,  because  recovery  is  rare, 
and  occurs  only  in  exceptional  cases,  influenced  by  very  favourable 
conditions  of  education  and  upbringing.  In  these  few  cases  the 
energies,  weapons  of  defence  of  the  mind,  are  latent,  but  if  well 
disciplined  and  well  directed,  may  finally  get  the  better  of  the 
invaders,  who  are  always  ready  to  resume  their  dominion.  In  the 
greater  number  of  cases,  however,  the  obsessions  gain  ground,  and 
we  have  not  one  only,  but  five,  ten,  or  a great  number  of  obsessions 
succeeding  one  another  or  coexisting. 

The  law  of  association  and  the  panophobic  condition  assist  the 
gradual  extension  of  the  dominion  of  obsessions.  Fear  terrorizes 
and  rules  ; perception  assumes  always  the  same  character  ; the  power 
of  judgment  becomes  more  confused,  and  its  m.eans  of  defence  are 
continually  impoverished.  The  personality  is  very  little,  if  at  all, 
disaggregated,  and  can  almost  always  be  recognised  for  a long  period 
as  being  abandoned  to  its  destiny,  tired  of  reacting. 

It  is  rarety  that  the  malady  of  obsessions  is  transformed  into 
other  forms  of  psychopathy.  Pitres  and  Regis  report  five  cases 
that  they  observed,  and  in  these  they  note  the  passage  of  the  obses- 
sion into  anxious  melancholia  with  ideas  of  delirium  or  hallucina- 
tions. I believe  that  when  Falret,  Magnan,  and  Legrain  afirrmed 
decisively  that  there  is  never  observed  even  the  slightest  modifica- 
tion of  the  syndrome  of  obsessions,  they  did  not  take  note  of 
melancholia  with  anxiety,  which  I consider  to  be  by  no  means  rare. 
The  slow  passage  to  rudimentary  paranoia  also  obliges  me  to  range 
myself  with  ^leynert,  Schafer,  \\fille,  Kraepelin,  Wernicke,  ^lorselli, 
Mickle,  and  Seglas,  who  have  observed  transformation  of  the  syn- 
drome into  systematized  hypochondriacal  delirium.  The  example 
already  quoted  b}”  me  goes  to  prove  this  transformation,  which  is. 
(piite  independent  of  the  epileptic  character  of  some  forms,  as  noted 
by  Mickle. 

Sometimes  there  are  complications  with  other  maladies,  as  I 
found  in  the  case  of  a young  woman  affected  b}*  syringomyelia. 


FIXED  IDEAS  AND  OBSESSIONS 


643 


Suicide  also  is  rare.  The  subjects  of  obsession  are  undecided, 
always  tormented  by  the  doubt  whether  they  should  or  should 
not  do  anything,  and  frequently  they  think  of  suicide,  but  cannot 
make  up  their  minds  to  it.  When  the  obsession,  ideative  or  motor, 
has  lasted  for  a long  time,  and  the  reaction  in  consciousness  has  been 
weakened,  suicide  becomes  less  probable. 

The  course  is  different  when  the  obsessions  occur  in  individuals 
who  are  well  constituted  and  of  good  cerebral  development,  but 
who  have  become  neurasthenic  owing  to  unfavourable  conditions 
of  life.  Such  patients  have  a richer  fund  of  resources,  and  their 
consciousness  more  easily  recovers  its  eliminating  power.  In  the 
struggle  against  the  invader  or  the  parasite  there  is  a greater  possi- 
bility of  victor}^  for  the  neurasthenic  subject  who  has  been  originally 
of  good  mental  constitution.  Among  those  whose  history  I have 
been  able  to  follow,  and  whom  I have  treated  directly,  I reckon  a 
reassuring  proportion  of  recoveries. 

Therapy. — There  are  children  with  hereditary  taint  who  very 
early  show  a tendency  to  fixed  ideas,  being  preoccupied  for  a long 
time  with  some  impression  that  they  have  received,  frequently 
asking  the  same  question  over  and  over  again,  and  in  given  cir- 
cumstances showing  the  same  exaggerated  fear.  They  are  always 
highly  emotional.  The  first  duty  of  the  medical  man  is  to  see  that 
such  children  receive  the  most  assiduous  care,  the  condition  of  their 
organism  being  improved  and  the  kinaesthesis  strengthened  by 
muscular  exercises,  while  the  mind  is  reinvigorated  by  well-selected 
mental  exercises,  proportioned  to  the  power  and  nature  of  the 
child’s  intellect.  In  developmental  psychasthenic  subjects  with  a 
tendency  to  obsession  the  utmost  that  can  be  done  is  reduced  to 
the  above.  In  these  subjects,  when  the  malady  is  well  developed, 
and  maturity  has  been  reached,  our  therapeutic  resources  will  in 
most  cases  be  exhausted  by  time  and  by  the  tenacity  of  the  obses- 
sion. There  are  soils  that  always  produce  a great  many  parasitic 
plants,  from  which  the  industry  of  the  cultivators  cannot  clear 
them.  As  a rule,  these  tracts  are  those  that  reward  the  labourer 
least.  The  same  thing  happens  in  the  mind  of  the  subjects  alluded 
to.  Cultivate  them  as  you  will,  the  result  will  always  be  a small 
product  of  inferior  quality  ; a number  of  useless  parasitic  germs 
exhaust  the  soil,  destroying  with  their  branches  and  roots  the  few 
good  plants,  which  grow  phthisical  and  sickly.  Obsessions  change, 
are  transformed,  give  periods  of  respite,  and  spring  up  again,  accord- 
ing to  the  circumstances  of  the  patient’s  life.  It  is  very  rarely  we 
manage  to  eliminate  them  altogether.  Intelligent  prophylaxis, 
well  studied  and  applied  in  time,  will  secure  the  reinvigoration  of 
many  weak  mental  organisms,  and  will  restore  the  conditions  that 
render  possible  the  elimination  of  all  useless  and  parasitic  products 
from  the  field  of  consciousness. 


41 — 2 


644 


PSYCHIATRY 


For  obsessions  that  have  developed  in  individuals  of  good 
mental  constitution,  but  who  have  become  neurasthenic,  and  for 
the  obsessions  of  hysterical  subjects,  the  treatment  is  the  same  as  in 
neurasthenia,  of  which  we  shall  speak  in  the  next  chapter.  It  can 
be  summed  up  in  a few  words  : relieve  the  neurasthenic  from  the 
action  of  all  exhausting  influences,  raise  the  tone  of  the  kinsesthesis 
by  well-graduated  and  selected  muscular  exercises,  elevate  the 
mental  tone,  and  inspire  him  with  confidence  born  of  the  authority 
of  the  medical  man,  and  the  sureness  of  his  judgment.  Electricity^, 
fresh  air,  and  water,  are  the  other  great  resources  of  the  physician  ; 
all  the  rest  are  rubbish. 

It  is  very  rarely  that  we  meet  with  conditions  that  demand 
the  confinement  of  such  sufferers  in  asylums,  and  even  when 
seclusion  is  advisable,  it  is  rarely  that  it  is  of  any  use.  The 
discussion  raised  by  Westphal,  who  emphasized  the  injury  done  by 
confinement,  has  been  continued  down  to  the  time  of  Rouillard 
and  Iscovesco,  who  consider  confinement  necessary.  It  reduces 
itself  to  a simple  question  of  opportunity  and  selection. 

No  doubt  the  impulsive  forms  and  those  of  delirious  or  halluci- 
natory content  sometimes  require  confinement,  but  here  the  opinion 
of  the  medical  man  must  be  decisive  and  responsible  in  each  case. 
The  physician  should  take  into  account  not  only  the  nature  of  the 
obsession,  but  also  the  character  of  the  patient,  the  circumstances 
and  the  surroundings  in  which  he  is  obliged  to  pass  his  life.  Some- 
times the  patients  themselves  ask  to  be  sent  to  an  asylum,  but  in 
most  cases  this  should  neither  be  advised  for  them  nor  imposed 
upon  them. 

A great  deal  has  been  said  and  written  about  treatment  by 
suggestion,  either  when  the  patient  is  awake,  or  when  under  the 
influence  of  common  hypnotism.  It  would  be  well  for  us  not  to 
form  any  illusions  on  this  point.  Certain  clinicians  who  obtained 
some  measure  of  success  lost  no  time  in  publishing  their  results, 
and  these  opened  many  avenues  to  hope  ; but  when  we  compare 
the  rarity  of  published  cases  of  cure  by  these  means  with  the  fre- 
quency of  the  malady  of  obsession,  we  are  forced  to  attribute  to 
suggestion  only  a very  modest  value.  I have  already  spoken  of  the 
‘ intelligent  authority  ’ that  the  medical  man  should  exercise  over 
patients  of  this  kind,  and  it  is  in  that  phrase  that  we  find  the  essence 
of  the  idea  of  suggestion  when  the  patient  is  awake.  The  real 
office  of  suggestion  is  to  supplement  with  words  of  authority  that 
deficiency  of  mental  energy  in  the  neurasthenic  subject  which 
prevents  him  from  eliminating  the  useless  products  that  form  the 
basis  of  the  obsession  ; to  put  new  objectives  before  him  ; to  pro- 
voke new  emotions  ; to  study  and  get  to  know  the  nature  of  the 
patient  and  his  tendencies,  in  order  to  cultivate  seeds  that  have 
not  germinated ; and,  above  all,  to  reinforce  the  kinaesthesis, 
whicli  gives  more  tone  to  the  normal  content  of  the  mind,  and 


FIXED  IDEAS  AND  OBSESSIONS  645 

which,  through  its  own  intrinsic  energ}^,  will  eliminate  useless 
products. 

I do  not  know  whether,  as  Janet  says,  it  is  really  in  our  power 
to  reconstitute  a personality  that  has  been  disaggregated,  or  to 
disaggregate  a personality  that  has  embodied  in  it  new  obsessions, 
but  which,  we  must  admit,  preserves  its  former  identity,  except 
that  all  the  mental  components  are  inhibited,  so  that  they  lose 
energy,  and  therefore  the  power  to  direct  and  to  eliminate  the 
content  of  the  obsessions. 

The  hopes  conceived  of  hypnotism  as  a means  of  treatment  of 
obsessions  are  fading  every  day,  for  every  clinician  who  has  any 
extensive  professional  experience  must  be  convinced  of  the  useless- 
ness of  all  efforts  to  hypnotize  persons  with  obsessions.  As  a rule, 
these  latter  resist  the  efforts  of  the  best  and  most  capable  hypnotists, 
unless  they  are  morphinists  or  such-like.  The  worst  of  the  matter 
is  that  the  sufferers  themselves  believe  in  hypnotism,  and  of  them- 
selves will  ask  to  be  hypnotized.  After  a few  seances,  when  they 
find  that  it  is  inefficacious,  they  lose  confidence  again,  and  become 
discouraged,  so  that  I am  now  making  it  a rule  not  to  resort  to 
common  hypnotism  unless  I have  tried  every  other  method  of  treat- 
ment in  vain,  or  in  cases  where  the  subjects  are  decidedly  hysterical, 
and  most  especially  in  the  case  of  women. 

I am  not  unaware  that  we  have  not  always  the  virtue  of  per- 
severance, and  that  our  patients  are  very  easily  discouraged  after 
a few  seances  that  have  had  no  effect,  so  that  I cannot  therefore 
absolutely  deny  the  efficacy  of  hypnotism  until  we  have  adopted 
the  method  that  has  already  been  inaugurated  by  a few  others. 
In  this  connection  I must  allude  to  the  cases  of  Bramwell  Milne 
(Brain,  1896),  who  had  nine  recoveries  from  various  forms  of  obses- 
sion, thanks  to  hypnotism  induced  after  a more  or  less  lengthy  pre- 
paration. I consider  that  he  has  been  the  most  fortunate  of  all 
who  have  tried  a similar  method  of  treatment,  and  his  example  has 
not  been  followed  by  imitators  so  persevering  as  himself,  nor  by 
persons  of  great  good  fortune. 


CHAPTER  X 


NEURASTHENIA 

Neurasthenia  is  a particular  state  of  the  nervous  system  in  which 
the  nervous  energy,  under  whatever  form  it  be  displayed,  is  below 
the  normal  minimum  relatively  to  each  individual,  and  below  the 
average  of  the  race  to  which  he  belongs.  This  deficiency  of  energy, 
total,  or  limited  to  certain  functions,  is  always  accompanied  by  a 
great  alteration  of  the  kinaesthetic  sense  in  the  direction  of  depression, 
by  exalted  emotive  excitability  with  diminution  of  inhibitory 
power,  by  greater  instability  of  character,  by  diminished  efficacy  of 
the  product  of  labour,  and  by  an  extraordinary  number  of  somatic 
phenomena.  These  last,  subjective  and  objective,  are,  as  it  were, 
the  conscious  point  of  the  malady,  whence  it  radiates  into  all 
departments  of  the  nervous  activity,  weakening  and  disturbing  their 
connections,  so  that  their  hampered  and  inefficacious  action 
aggravates  the  discomfort  and  reacts  upon  the  character. 

The  insufficiency  of  the  various  functions,  the  sense  of  weariness, 
the  pains  and  paraesthesias,  the  visceral  disorders,  the  palpitation, 
or  the  oppression,  produce  an  intonation  of  sadness  and  of  continual 
preoccupation  with  one’s  own  health. 

It  is  a difficult  matter  to  find  a neurasthenic  subject  who  is 
contented.  Even  when  such  a one  would  appear  to  be  happ}^, 
the  gaiety  even  going  as  far  as  the  maniacal  form  of  neurasthenia, 
which  is  very  rare,  such  gaiety  is  superficial  and  inconstant  ; it  has 
an  intermixture  of  other  phenomena,  and  is  characterized  by  great 
instability  of  the  ego. 

Neurasthenic  subjects  never  enjoy  life.  As  the  pleasure  of 
existence  arises  from  the  facility  with  which  resistances  are  over- 
come without  too  great  strain  upon  the  organs,  the  neurasthenic 
subject  who  either  does  not  overcome  such  resistances,  or  does 
so  only  at  tlie  cost  of  suffering,  falls  into  a state  of  despair  and 
discomfort.  His  painful  consciousness  of  himself  makes  him 
acquainted  with  his  malady,  and  furnishes  him  with  matter  for  a 
pessimistic  interpretation  of  the  state  of  his  health,  and  makes  him 
take  a gloomy  view  of  his  future,  so  tliat  he  comes  to  believe  that 
he  is  more  seriously  ill  than  is  really  the  case. 

646 


NEURASTHENIA 


647 


A sensation  of  tingling  in  the  limbs  on  one  side  is  associated 
with  the  fear  of  an  attack  of  apoplexy.  A slight  tachycardia  or 
difficulty  in  breathing,  or  a pain  in  the  region  of  the  heart,  which 
is  very  frequent,  generates  the  conviction  of  the  existence  of  serious 
heart  disease.  Difficulty  in  digestion  gives  him  the  conviction 
that  he  has  an  incurable  disease  of  the  stomach.  This  preoccupa- 
tion is  rapidl}^  transformed  into  true  h37pochondria,  irrational, 
persistent,  monotonous,  and  impervious  to  any  reasoning.  The 
feeling  of  malaise  which  is  inseparable  from  the  pathological  fatigue 
prevents  the  development  of  any  energy  and  produces  discomfort. 

Under  the  tyranny  of  this  state  of  mind  the  neurastheniac 
consults  all  the  medical  men  within  reach,  and  if  the  malady  con- 
tinues, as  frequently  happens,  he  puts  himself  into  the  hands  of 
quacks,  or  he  tries  by  himself  everything  that  is  suggested  by  his 
friends,  to  whom  he  recounts  his  sufferings,  even  if  he  does  not 
adopt  the  suggestions  on  the  back  pages  of  newspapers,  and  experi- 
ment with  all  the  remedies  extolled  by  the  vendors  of  specifics  for 
neurasthenia.  With  the  exception  of  hysteria,  there  is  no  malady 
that  presents  psychic  disorders  so  varied  as  those  found  in  neuras- 
thenia ; nevertheless,  we  can  distinguish  three  groups — -the  emotive, 
the  intellectual,  and  the  somassthetic.  It  must  be  borne  in  mind, 
however,  that  the  three  pictures  presented  by  the  disease  are  not 
perfectly  distinct  ; there  is  simply  a prevalence  of  some  phenomena, 
giving  the  malady  a predominant  character. 

Emotive  neurasthenia  is  often  developmental,  and  includes  the 
following  subgroups  : 

1.  That  of  the  melancholiacs,  who  have  a sad  turn  of  mind,  are 
easily  discouraged  and  generally  weak,  taking  little  pleasure  in 
anything,  showing  little  confidence  in  themselves,  a tendency  to 
isolation,  indifference,  inhibition,  fits  of  anguish  of  monotonous 
ideative  content,  fear  of  death,  and  a tendency  to  suicide.  In 
slighter  cases  there  is  pessimism. 

2.  The  group  of  timid  subjects,  who  resemble  the  foregoing. 
In  these  patients  discouragement  and  hypersensibility  to  every 
exterior  stimulus  in  the  social  relations  are  predominant.  If  they 
have  to  speak  in  public  they  are  seized  with  a vague  fear,  palpitation, 
real  anguish,  and  clouding  of  the  intelligence.  This  happens  even 
to  theatrical  artists,  students  at  examinations,  etc.,  and  hence  such 
people  avoid  contact  with  the  external  world.  During  adolescence 
they  blush  and  turn  pale  on  the  slightest  occasion.  In  all  their 
relations  with  their  fellows  there  is  a prevailing  tendency  to 
subjection  (Hartenberg,  Francotte). 

3.  The  third  group  is  constituted  of  suspicious  and  jealous 
persons,  whose  dispositions  vary  with  their  temperaments.  They 
are  ver}^  numerous.  At  bottom  the  suspicion,  jealousy,  and  envy 
by  which  these  neurasthenic  subjects,  who  are  often  querulous  and 
malignant,  are  torn,  have  their  roots  in  their  own  weakness,  and  in 


648 


PSYCHIATRY 


their  uncertain  knowledge  of  their  relations  to  their  environment. 
This  form  may  remain  unaltered  for  a whole  lifetime,  but  it  may 
also  become  the  soil  of  development  of  delirious  ideas  (neurasthenic 
paranoia). 

4.  The  erethistic  form,  including  individuals  who  are  often  well 
developed  in  the  sphere  of  the  sentiments  and  the  intelligence,  but 
who  are  overexcited  and  greatly  moved  bv  the  slightest  stimuli, 
showing  exaggeration  in  their  judgments  and  actions,  over  which 
they  cannot  exercise  proper  control,  and  a useless  expenditure  of 
energy.  They  are  violent,  impulsive,  become  alarmed  at  trifles, 
and  precipitate  matters.  Sometimes  they  are  aggressive,  and 
intractable  both  at  home  and  abroad.  This  state  is  in  contrast 
with  their  habitual  goodness  or  serenity  under  normal  circum- 
stances. As  a rule  a gloomy  disposition  prevails,  but,  differing 
from  melancholic  subjects,  neurastheniacs  present  greater  varia- 
bility of  humour  during  periods  of  respite,  and  a constant  marked 
weakness  of  the  moderating  powers.  They  furnish  a certain 
proportion  of  the  delinquencies  of  passion. 

In  intellectual  neurasthenia  the  subject  himself  gives  the  measure 
of  the  loss.  For  some  time  past  he  has  been  unable  to  concentrate 
his  attention  (diminution  of  the  power  of  attention).  He  reads 
automatically  without  understanding  wdiat  he  reads,  and  so  he  is 
obliged  to  read  the  same  thing  over  again  (distraction  and  divaga-  : 
tion).  He  takes  no  part  in  conversations,  because  they  weary  him.  1 
He  IS  no  longer  fit  to  look  after  the  affairs  of  his  house,  because  he 
IS  incapable  of  adding  up  a long  account  or  of  followfing  a course  I 
of  ideas  for  any  length  of  time.  His  directive  power  over  his  ‘ 
thoughts  is  diminished,  and  other  thoughts  automatically  break 
uie  thread  of  ideas,  while  whatever  effort  he  can  make  to  recover 
It  is  short-lived,  and  wearies  him.  This  particular  disturbance  is  : 
almost  never  absent.  j 

The  defect  of  memory  is  notable.  The  reproduction  of  images,  ! 
of  notions,  and  of  thoughts  is  less  prompt,  less  easy,  and  less  faithful,  i 
so  that  errors  of  memory  are  frequent,  giving  rise  to  circumlocutions  ■ 
when  lie  cannot  find  the  proper  word.  The  weakened  power  of  ' 
association  also  shows  the  loss  to  the  cerebral  functions. 

The  products  of  S3mthesis  are  scarcer  and  of  low  value,  the  flow 
of  ideas  is  checked,  and  the  imagination  is  very  poor.  States  of 
neurasthenia  may  therefore  be  compared  to  states  of  protracted 
p lysiological  fatigue.  Just  as  the  ergographic  curves  are  not  so 
iig  1 a tei  piotracted  muscular  labour,  owing  to  exhaustion,  so  we 
n t le  same  thing  in  intellectual  labour.  After  a night’s  repose, 
or  when  the  brain  is  better  nourished  by  a well-digested  meal  and 
adequate  rest,  it  is  more  productive,  the  imagination  is  more  active, 
images  aie  moie  readily  called  up,  and  the  patient  makes  more  use 
o 11s  mte  ectual  patiimony.  The  lowering  of  the  mental  power 
may  go  to  such  a length  as  to  produce  real  mental  confusion— the 


NEURASTHENIA 


649 


neurasthenic  stupidity  of  Ziehen  and  other  authors.  Sometimes 
this  form  of  neurasthenia  is  latent,  and  the  subjects  become  aware 
of  it  onty  after  a fast  or  after  mental  labour  carried  on  longer  than 
usual.  In  such  cases  the  mind  soon  loses  its  habitual  lucidity  and 
wealth  of  ideas,  and  the  sufferers  are  no  longer  in  the  position  to 
express  their  own  thoughts  in  due  order,  according  to  a prearranged 
plan.  A discourse  that  was  to  have  lasted  an  hour  in  reality  lasts 
twenty  to  thirty  minutes,  and  often  the  most  interesting  matters 
are  omitted.  In  these  cases  the  threshold  of  fatigue  is  very  near 
to  the  commencement  of  work. 

Tormenting  doubt  coexists  with  this.  It  extends  from  inca- 
pacity to  come  to  a decision  when  difficulties  arise  in  important 
matters,  to  irresolution  in  matters  of  slight  moment  or  where  the 
course  is  clear,  and  in  its  last  stage  it  is  trivial  doubt  in  all  the 
simple  acts  of  life,  with  the  characteristics  of  the  malady  of  doubt 
described  in  the  preceding  chapter. 

With  the  diminution  of  the  reproductive  and  associative  power 
there  is  often  conjoined  the  tendency  to  emotive  fixity  of  impres- 
sions. Any  sensation  of  some  intensity  that  determines  states  of 
emotion  will  remain  for  a long  time  in  the  consciousness.  Many 
patients  consult  medical  men  specially  or  solely  about  tormenting 
permanence,  in  their  minds,  of  impressions  received.  This  is  the 
rudimentary  form  of  the  malady  of  obsessions.  These  individuals 
are  thus  obliged  to  think  of  things  they  have  no  desire  to  dwell  upon, 
and  they  can  find  no  escape  from  this  species  of  obsession,  which 
lasts  for  hours  and  is  renewed  on  every  possible  occasion  by  the 
most  diverse  causes.  With  this  mental  state  there  is  found  also  a 
certain  degree  of  aboulia,  with  predominance  of  automatism. 

We  have  already  mentioned  elsewhere  that  there  are  men  who 
think  of  doing  certain  things  and  desire  to  do  them,  but  are  incapable 
of  bringing  themselves  to  action,  for  this  requires  a higher  potential 
of  energy  in  order  to  overcome  internal  and  external  resistances 
(see  Part  IT).  Thus  the  thought  of  the  neurasthenic  subject,  even 
though  he  be  cultured  and  intelligent,  never  goes  beyond  a soliloquy, 
the  subject,  as  it  were,  speaking  to  himself  about  the  proposed 
action. 

This  is  one  of  the  main  causes  of  their  discomfort,  for  it  is 
completed  action  that  gives  an  individual  the  consciousness  of  his 
own  energy,  while  the  man  who  does  nothing  has  nothing  to  console 
himself  with,  and  often  becomes  a mere  critic  and  a pessimist. 

certain  degree  of  aboulia  is  always  found  in  neurasthenic 
subjects.  The  work  done  by  such  people  is  poor  and  interrupted, 
and  fatigue  easily  and  rapidly  overtakes  them,  so  that  they  abandon 
any  enterprise  that  they  may  just  previously  have  undertaken  with 
goodwill,  and  with  a conviction  of  success.  Perseverance  in  co- 
ordinated work  is  a form  of  energy  which  it  is  not  given  to  the 
neurastheniac  to  possess. 


650 


PSYCHIATRY 


Along  with  weakness  of  will  we  have  automatism,  which  may 
show  itself  in  every  action.  The  most  common  case  occurs  with 
the  lapsus  calami  in  writing,  and  such  slips  are  very  frequent  when 
the  brain  is  fatigued. 

As  a rule  the  character  of  the  sleep  is  changed.  It  is  no  longer  t 
restorative,  but  broken  and  filled  with  tormenting  dreams  that  leave 
the  subject  in  bad  humour  when  he  wakes.  j 

After  a few  hours’  sleep  the  patients  sometimes  waken  with  a ; 
start,  with  a vague  sense  of  fear  or  with  palpitation,  and  they 
cannot  go  to  sleep  again.  The  more  intelligent  among  them  read,  ' 
write,  or  walk  up  and  down  their  rooms  ; but  the  others  remain  in 
bed,  constantly  turning  from  one  side  to  the  other,  and  at  length  they 
become  frantic  and  despairing,  and  begin  to  foster  the  idea  of 
suicide.  Many  people  consult  their  medical  advisers  solely  for 
agrypnia  or  ahypnia,  and  the  anguish  they  suffer  from  it.  Some- 
times sleep  overpowers  them  in  the  midst  of  their  business,  or,  in 
the  case  of  scholars,  during  lessons.  This  makes  them  despair  all 
the  more,  especially  as  they  cannot  get  a wink  of  sleep  at  night. 

Somatic  Phenomena. — Among  these  the  most  prominent  are  the 
painful  phenomena,  which  somxtimes  assume  the  greatest  impor- 
tance in  the  symptomatology  of  neurasthenia.  In  the  first  place 
stands  headache.  This  assumes  various  characters,  and  is  variously 
localized,  being  frontal  in  some  cases,  occipital  or  temporal  in  others, 
and  sometimes  general  and  intense. 

Frontal  cephalalgia  is  sometimes  a sense  of  weight ; sometimes  it 
resembles  blows  with  a hammer,  or  is  like  a band  tightly  tied  round 
the  forehead  ; again,  it  may  resemble  a weight  pressing  on  the  head 
and  on  the  orbits  (neurasthenic  helmet),  while  the  eyes  are  heavy 
and  painful,  and  compression  appears  to  relieve  them.  This  form 
is  more  frequent  in  those  who  have  undergone  very  long  and  intense 
mental  labour.  It  may  be  considered  as  an  intensification  of  that 
sense  of  pressure  on  the  forehead  which  is  felt  after  attention  with 
effort  or  prolonged  mental  labour,  and  which  induces  people  to 
raise  the  hand  to  the  forehead.  From  this  sensation  to  frontal 
cephalalgia  is  onty  a matter  of  degree. 

Occipital  cephalalgia  is  compressive  and  penetrating,  and 
causes  much  more  intense  suffering  than  frontal  cephalalgia.  It  is 
sometimes  associated  with  vertigo  or  nausea,  and  in  such  cases 
if  is  accompanied  by  a profound  sense  of  ill-being,  as  of  approaching 
death.  General  cephalalgia  is  darting,  hammering,  compressive, 
constrictive,  etc.,  these  being  the  words  with  which  the  sufferers 
generally  express  themselves.  It  is  more  frequent  after  sexual 
excesses  or  prolonged  intellectual  labour,  and  especially  after  close 
attention.  In  these  cases  we  must  take  account  of  the  position  of 
the  head.  Those  who  study  when  lying  in  a horizontal  position  are 
much  less  subject  to  it  When  one  is  attentive  in  an  erect  position 


NEURASTHENIA 


651 

the  muscles  of  the  neck  are  tired  by  the  flexion  of  the  head,  and 
pain  is  felt  at  the  line  of  insertion  of  those  muscles.  From  that 
point  it  sometimes  spreads  to  the  crown  of  the  head  or  further 
forward.  In  very  many  cases  the  sensation  is  as  though  there 
were  some  barrier  in  the  way  of  the  ideas,  forming  a painful  obstacle 
of  more  or  less  alarming  character.  I shall  not  speak  of  other  forms 
of  cephalalgia— for  example,  hemicrania— which  form  quite  definite 
syndromes,  and  are  developed  on  a base  of  neurasthenia. 

As  a rule,  neurasthenic  cephalalgia  increases  with  labour  and 
with  fasting,  and  diminishes  or  ceases  altogether  after  meals. 
Sometimes  the  sufferers  complain  of  a sensation  of  emptiness  m 

the  head.  • • 1 

Rachialgia  was  noted  by  pathologists  long  before  the  clinical 

figure  of  neurasthenia  had  been  well  defined. 

It  has  also  been  termed  spinal  irritation,  and  Hammond  attri- 
buted it  to  ischsemia  of  the  posterior  columns.  It  is  a pungent  or 
burning  pain  that  is  felt  along  the  spine,  more  particularly  at  certain 
points,  from  which  it  spreads  to  the  trunk  and  the  limbs.  It  may 
become  excessively  intense,  and  it  continues  even  when  the  patient 
is  at  rest.  Not  even  repose  in  bed  will  mitigate  it.  It  causes  un- 
bearable discomfort,  and  may  resist  all  treatment  for  a very  long 
time. 

Circumscribed  spinal  pains,  true  signs  of  neurasthenia,  aie  very 
frequent,  not  to  say  constant.  It  is  rarely  that  we  find  a neuras- 
thenic subject  who  does  not  complain  of  a pain  in  the  lumbo-sacral 
region.  This  pain  also  causes  a sensation  of  weight,  with  deep- 
seated  acute  painful  pressure.  It  is  very  frequent  at  the  points  of 
insertion  of  the  dorso-lumbar  muscles,  but  sometimes  is  felt  at  the 
sacrum,  the  coccyx,  or  more  rarely  the  first  dorsal  vertebra.  It  is 
much  more  intense  after  sexual  abuses,  but  very  often  it  is  the  effect 
of  protracted  labour  of  the  lumbar  muscles  in  individuals  who  are 
obliged  to  stand  a long  time  on  their  feet.  I have  frequently 
observed  it  in  shop  employees  and  in  glove-cutters. 

Other  local  pains  (topoalgias)  are  found  in  neurasthenic  subjects 
in  the  viscera,  in  the  cardiac  region,  etc. ; but  they  are  less  frequent, 
although  they  alarm  the  subjects  a great  deal  more  than  the  spinal 
pains.  These  are  a veritable  nursery  of  hypochondriacal  ideas. 

There  are  some  neurasthenic  subjects  who,  in  addition  to  a con- 
tinuous feeling  of  weariness  and  a strong  desire  to  lie  down  to  rest, 
suffer  pains  in  the  muscles  whenever  they  make  the  slightest  muscular 
effort.  One  will  mount  a horse,  but  be  compelled  to  dismount  in 
ten  minutes  owing  to  pains  in  the  thighs,  the  back,  and  the  arms, 
depriving  him  of  the  power  to  keep  the  horse  under  control.  Another 
has  to  relinquish  his  game  at  billiards  after  a few  strokes  with  the 
cue,  on  account  of  the  muscular  pain  he  suffers.  When  at  rest, 
these  subjects  are  well  enough. 

Hyperaesthesia  is  found  in  all  the  other  senses.  A light  that  is 


652 


PSYCHIATRY 


at  all  intense  or  any  loud  noise  cannot  be  tolerated,  or  will  cause 
great  discomfort  and  produce  weariness.  The  neurasthenic  subject 
finds  that  his  visual  power  is  very  much  diminished  if  he  looks  at 
a luminous  body  for  even  a very  short  time. 

On  the  other  hand,  paraesthesia  is  common,  especially  in  women. 
The}^  complain  of  tinglings,  shiverings,  and  sensations  of  insects 
crawling  about  in  their  hair  or  over  their  skins.  They  have  a 
feeling  of  cold  or  of  heat,  associated  with  an  indefinite  sense  of  dis- 
comfort in  the  calves  of  the  legs.  They  suffer  from  heat  in  the  face,  a 
burning  sensation  in  the  head,  and  scorching  heat  in  hands  and  feet. 

J ust  as  the  affective  excitability  is  augmented,  so  the  superficial 
and  the  deep  reflexes  are,  as  a rule,  exalted.  Neither  abolition  of 
the  patellar  reflexes  nor  complete  rigidity  of  the  pupil  is  a pheno- 
menon of  simple  neurasthenia,  and  when  these  symptoms  are  found 
one  is  warranted  in  thinking  of  some  other  process. 

Alongside  these  fundamental  characteristics  of  neurasthenia, 
which  we  might  regard  as  general,  there  coexist,  or  even  predominate 
in  many  cases,  functional  disturbances  of  single  organs,  which  some- 
times become  so  intense  as  to  conceal  the  other  disorders,  and  give 
place  to  what  goes  under  the  name  of  partial  neurasthenia.  This 
latter  assumes  various  forms. 

Professional  N eur asthenia  (Professional  Dyskinesis). — Writing  for 
a long  time  causes  fatigue  of  the  nervous  mechanism  specialized  for 
this  function.  In  such  a case,  every  time  the  subject  prepares  to 
write  he  is  seized,  even  from  the  very  start  or  after  he  has  written  a few 
lines,  by  a painful  feeling  of  fatigue  in  the  arm,  or  by  a spasm  that 
prevents  him  continuing  (mogigraphia).  What  happens  to  writers 
happens  also  in  similar  circumstances  to  pianists,  violinists,  etc. 

Another  person  who  may  have  worked  for  a long  time,  giving 
his  attention  to  calculations — an  accountant,  to  take  a particular 
example — cannot  make  a calculation  of  an}^  importance  without 
being  subject  to  keen  suffering,  and  that  even  although  he  has 
retained  all  his  intellectual  patrimony  and  his  habitual  vivacity. 
Some  persons  who  read  much  become  so  fatigued  that,  whene\'er 
they  take  up  a book  to  read,  they  are  subject  to  an  undefined  sense 
of  discomfort,  with  pains  in  the  eyes  and  occiput  (anagnosiasthenia, 
Bianchi). 

Sexual  abuses,  and  above  all  misuse  or  nocturnal  emissions, 
wear  out  the  centre  special  to  this  function  (impotence  from  ex- 
haustion). The  disorders  of  the  sexual  function  are  of  the  most 
varied  character.  Sometimes  sexual  desire  is  lacking,  or  it  may 
be  much  more  intense  than  is  natural,  but  with  little  vigour.  Erec- 
tion is  weak  and  insufficient,  with  rapid  ejaculation  ante  introitiim. 
Nocturnal  pollutions  and  spermatorrhoea  are  frequent.  There  is 
great  exhaustion,  pain  in  the  lumbar  region,  irritabilit}^  lowering 
of  the  intellectual  powers,  and  Itypochondriasis,  especially  after 
more  or  less  unsuccessful  coitus  or  after  pollution. 


NEURASTHENIA 


653 


General  or  partial  neurasthenia  is  frequently  accompanied  by 
vaso-motor  disturbances.  i\Iany  neurasthenic  subjects  are  very 
prone  to  blush  or  turn  pale  under  the  slightest  impression,  and 
suffer  from  palpitation,  tachycardia,  bradycardia,  arhythmia,  or 
even  attacks  of  angina  pectoris,  asthma,  oppression,  or  serious  dis- 
turbances of  the  digestion.  The  predominance  of  these  phenomena 
has  caused  some  to  speak  of  visceral  forms  of  neurasthenia,  and 
especially  of  gastric,  cardiac,  or  respiratory  neurasthenia. 

In  gastric  neurasthenia  the  appetite  is  diminished,  or  sometimes 
exaggerated,  and  in  this  case  nothing  can  satisfy  it,  for  there  is  a 
pressing  and  urgent  impulse  to  eat.  In  the  majority  of  these  cases, 
however,  the  digestion  is  slow  and  painful,  so  that  the  food  remains 
in  the  stomach  many  hours  after  it  is  eaten,  and  there  is  frequently 
a deficiency  of  the  gastric  secretions  or  some  anomaly  in  the 
chemistry,  such  as  diminution  or  excess  of  chlorides  (Huschard, 
Leube,  Bouveret).  Huschard  says  that  the  innervation  of  the  stomach 
is  defective,  and  that  the  defect  is  not  limited  to  the  muscles  of  the 
stomach,  but  affects  also  the  glandular  secretion.  There  is  constipa- 
tion, generation  of  gas,  and  a feeling  of  great  discomfort,  sometimes 
pains  in  the  epigastric  region  (topoalgia,  Blocq),  dejection,  and 
somnolence  during  the  hours  of  digestion.  One  of  the  character- 
istics of  this  form  is  its  mutability  (Linossier,  ‘ V ariahilitie  des 
secretions  chez  les  neurastheniques,^  Bull,  de  Therapeutique,  1900,  and 
others).  The  same  subject  will  digest  well  one  day,  and  not  at  all 
another  day.  For  a short  time  he  can  digest  certain  foods,  such  as 
milk  and  eggs,  but  afterwards  he  cannot  tolerate  them  at  all,  as  the 
chemical  processes  are  altered,  and  even  heavier  foods,  such  as 
pulse,  tomatoes,  and  capsicums,  are  better  digested. 

In  some  cases  intestinal  troubles  are  associated  with  the  gastric 
phenomena — for  example,  abdominal  pain,  meteorism,  flatulence, 
and  constipation  (intestinal  neurasthenia). 

The  cardiac  syndrome  (cardiac  neurasthenia)  has  been  known 
for  a long  time  (Bouchut,  Beard,  Rosenthal,  Anjel,  Weber,  and 
Krishaber).  It  is  represented  by  an  alarming  group  of  symptoms  : 
irregular  pulse,  palpitation,  tachycardia,  permanent  or  in  paroxysms, 
pseudo-angina  pectoris,  with  pains  and  anguish.  Sometimes  there 
is  arhythmia  (the  delirium  cordis  of  Huschard),  in  paroxysms  and 
with  anguish.  Sometimes  also  the  pulse  is  weak  and  compressible, 
and  there  is  a tendency  to  fainting  attacks.  In  these  cases,  and 
in  those  with  palpitation  and  arhythmia,  I have  frequently  observed 
that  the  first  mitral  sound  is  very  impure,  and  sometimes  sub- 
stituted by  a real  murmur,  accompanied  occasionally  by  diminished 
arterial  tension,  and  a slight  dilatation  of  the  cardiac  area.  The 
diagnosis  can  be  better  formulated  after  a few  days’  observation. 
The  same  thing  happens  with  these  cardiac  phenomena  as  with  the 
gastric — they  disappear  one  day  and  reappear  another. 

The  skin  is  sometimes  arid,  dry,  and  scorching,  while  at  other 


654 


PSYCHIATRY 


times  it  is  cold  and  covered  with  very  annoying  persistent  perspira- 
tion, especially  in  the  hands  (hyperhydrosis).  l 

The  tissue  metabolism  is  by  no  means  exempted,  in  proof  of  | 
which  it  will  suffice  to  mention  the  frequency  of  phosphaturia.  In  | 
addition  to  those  subjects  who  preserve  their  normal  constitution,  j 
there  are  certainl}^  others  who  become  emaciated  and  rapidly  lose  j 
weight,  while  there  are  others,  again,  who  are  excessively  fat  (poly-  | 
sarcic  neurastheniacs).  j 

Physiopathology. — The  pathological  concept  of  neurasthenia  is  | 
summed  up  in  the  idea  of  pathological  fatigue.  All  the  psychic 
phenomena  that  enter  into  the  clinical  picture  of  the  disease  are  the 
direct  consequence  of  the  sense  of  weariness,  partial  or  general,  and 
of  incapacity,  in  conjunction  with  the  psychic  orientation  of  each 
man  and  his  intellectual  and  emotive  content,  or,  in  other  words, 
the  individual  factor. 

Neurasthenia  is  one  of  the  maladies  that  can  be  localized  with 
most  certainty. 

In  Part  I.  we  mentioned  that  in  the  somaesthetic  zone  of  the 
cortex  are  represented  the  circulation,  the  secretions,  and  aU  the 
other  organic  functions,  in  addition  to  the  muscular  sense,  ^nd  the 
tactile  sense,  giving  rise  to  that  complex  and  obscure  sensation  of 
one’s  own  existence  that  is  termed  kinaesthesis. 

In  this  zone  lies  the  nucleus  of  consciousness  and  of  the  joy  of 
existence,  emanating  from  the  harmonious  performance  of  their 
functions  by  the  various  parts  of  the  organism.  When  it  is  con- 
sidered that  the  kinaesthesis  is  always  fundamentally  altered  in  all 
forms  of  neurasthenia,  there  arises  spontaneously  the  pathological 
conception  of  neurasthenia  as  a malady  referable  essentially  to  the 
somaesthetic  zone. 

It  is  true  that  the  symptomatic  complex  of  the  malad}^  as 
de\’eloped  in  all  its  forms,  including  fatigue,  malaise,  incapacity, 
and  psychic  phenomena  such  as  irritability,  hypochondriasis,  super- 
ficiality of  judgment,  deficient  power  of  attention,  weakness  of 
memory,  affective  excitability,  and  fixed  ideas,  must  have  a much 
more  extensive  field  on  the  cerebral  mantle,  and  one  that  cannot 
always  be  defined.  The  partial  forms  are  more  readily  localized. 
Mogigraphia  may  have  its  seat  in  the  cortical  centre  of  writing, 
but  there  is  nothing  that  will  authorize  us  to  exclude  lesion  of  the 
spinal  medulla.  Impotence  may  be  spinal  or  cerebral.  Anagnosi- 
asthenia  emanates  from  the  centre  of  reading,  but  it  may  come 
also  from  the  subcortical  centre  of  the  motor  muscles  of  the  eye 
(asthenopia). 

These  few  considerations  will  convince  us  it  is  only  general  hypo- 
chondriacal neurasthenia  that  can  be  localized  in  the  somaesthetic 
zone.  Other  partial  forms  may  be  localized  also  in  other  parts  of 
the  nervous  system,  but  we  cannot  exclude  the  possibility  of  par- 


NEURASTHENIA 


655 


ticipation  the  senso-motor  zone.  To  us  who  consider  emotion 
as  a psycho- somatic  complex,  inseparable  in  its  components — repre- 
sentative and  somatic — it  does  not  seem  plausible  that  there  should 
be  localization  in  the  vaso-motor  centres.  On  the  other  hand,  we 
cannot  attribute  much  value  to  the  hypothesis  advanced  by  Meynert, 
and  accepted  by  some  authors,  among  whom  is  Binswanger — namely, 
that  the  cortical  organs  are  the  seat  of  the  weakness,  and  the  sub- 
cortical the  seat  of  the  irritation.  It  is  an  old  but  unfounded  doc- 
trine, which  is  on  a par  with  the  other  theory  that  the  subcortical 
organs  form  a compensation  for  the  cortical  ones  that  are  destroyed. 

Pathological  Anatomy. — We  have  rather  an  intuitive  notion  of 
the  existence  of  an  anatomo-pathological  process  in  neurasthenia 
than  any  proof  of  it.  This  intuition  or  assumption  is  based  on  the 
existence  of  a numbei  of  forms  of  neurasthenia  which  are  gradually 
transformed  into  more  serious  maladies. 

It  is  well  known  that  some  cases  of  impotence,  however  much 
they  may  be  treated,  reappear  in  the  course  of  a few  years  as  the 
prelude  to  tabes  dorsalis  or  to  progressive  paralysis.  Forms  of 
cerebral  exhaustion  become  slowly  aggravated,  and  in  course  of 
time  reveal  themselves  as  paralytic  dementia,  as  occasionally 
happens  with  mogigraphia. 

If  to  these  facts  there  be  added  the  positive  findings  in  the 
traumatic  forms  of  neurasthenia,  for  the  study  of  which  we  are 
already  in  possession  of  experimental  data,  we  may  conclude  that 
it  is  permissible  to  assume  the  existence  of  an  anatomo-patho- 
logical process  in  the  nervous  tissue,  although  we  cannot  clearly 
define  it. 

Even  at  this  date  I cannot  do  better  than  reproduce  here  what 
I wrote  some  years  ago  on  the  subject  of  anagnosiasthenia  : 

‘ Admitting  the  principle  that  all  functions,  simple  or  complex, 
are  merely  co-ordinations  manifested  by  definite  anatomical  terri- 
tories, and  recognising  the  truth  of  the  other  principle  that  the 
functions  of  a given  nervous  territory  are  strictly  related  to  the 
process  of  disintegration  and  reintegration  of  that  same  territory, 
it  follows  as  a consequence  that  excessive  labour  on  the  part  of  a 
given  nervous  region  must  produce  excessive  disintegration,  which 
will  end  in  the  death  of  the  nervous  elements  unless  we  have  the 
intervention  of  two  favourable  conditions  : on  the  one  hand, 
abundant  nutrition,  which  refurnishes  the  nervous  element  with 
organic  material  to  make  up  for  what  has  been  consumed,  and,  on 
the  other  hand,  prompt  elimination  of  all  the  products  of  organic 
disintegration.  Only  those  elements,  however,  that  were  originally 
robust  possess  a high  power  of  assimilation  and  elimination  ; and 
where  this  double  power  is  unequal  to  the  demands  upon  it  for 
the  performance  of  the  function,  the  consequence  will  be  either 
insufficient  nutrition,  and  therefore  wasting  away  of  the  nervous 


656 


PSYCHIATRY 


element,  or  insufficient  elimination  and  consequent  intoxication  of 
that  element,  or  both  of  these  together. 

‘ On  either  of  the  two  hypotheses  the  nervous  element  becomes 
impoverished,  unequal  to  its  ordinary  work,  and  may  even  die 
(degeneration).’  (‘  Di  una  nuova  forma  di  nevrastenia  parziale — 
Anagnosiastenia^  Annali  di  Nevrologia,  1895.) 

.Etiology. — Neurasthenia  is  hereditary  or  acquired.  The  first 
of  these  comprises  developmental  forms  of  all  degrees.  The  different 
countries  and  various  races  are  not  equally  subject  to  it.  The 
disease  is  more  frequent  among  the  Hebrews  (consanguineous 
marriages  ?),  the  French,  the  Russians,  the  Americans,  and  the 
Italians,  and  less  frequent  among  the  Germans  and  the  Scandi- 
navians. 

Sexual  abuse,  especially  if  precocious,  disuse,  or  misuse,  nocturnal 
emissions,  and  the  prolongation  of  sexual  stimuli,  occasion  a notable 
number  of  cases  of  neurasthenia.  The  most  potent  cause  of  all, 
however,  is  onanism  during  the  period  of  greatest  development  of 
the  body,  and  at  the  time  when  the  most  intense  mental  labour  is 
demanded  in  our  schools  and  gymnasia. 

In  Italy  a considerable  contributory  factor  is  the  method  and 
organization  of  our  secondary  schools.  The  multiplicity  of  subjects 
the  very  frequent  change  of  teachers  for  every  year’s  course  in  the 
gymnasium  or  the  lyceum,  with  consequent  change  of  method  and: 
of  books  for  the  same  subject,  particularly  in  the  case  of  grammar 
the  disturbances  to  memory  due  to  such  a method  ; the  crowd  of 
improvised  teachers  who  are  destitute  of  the  very  elements  of' 
pedagogic  knowledge,  but  full  of  Greek,  Latin,  and  ill-digested 
philosophy  ; the  slight  influence  exercised  by  the  rectors  over  the 
teachers,  who  are  left  full  liberty  to  cram  into  the  minds  of  the. 
children  more  than  they  can  digest,  and  Heaven  knows  by  what  a- 
method  ; the  persistent  stupidity  of  subjecting  the  youths  attending ' 
the  University  to  a very  great  number  of  examinations,  and  compel-^ 
ling  them  to  study  subjects  that  are  frequently  useless  ; the  absence  \ 
of  any  notion  of  the  physiology  of  the  mind  in  the  case  of  the! 
majority  of  the  directors  of  public  instruction  ; and  the  misoneism 
that  prevails  in  this  respect  in  the  legislative  bodies,  have  caused 
more  hurt  to  the  minds  of  Italian  youth  than  anyone  can  imagine. 

Overwork  is  less  hurtful  to  adults.  Still,  it  is  certain  that  the 
mental  efforts,  the  preoccupations,  the  anxieties,  the  multiplicity 
of  interests,  the  whirl  of  activity,  to  which  men  are  driven  by  their 
increasing  wants  and  unbridled  desires,  the  increased  difficulties  of 
life,  ambitions,  and  the  overmastering  desire  for  enjoyment,  result 
in  a number  of  cases  of  neurasthenia,  by  no  means  small,  especially 
where  there  is  predisposition  to  the  disease.  As  frequently  happens, 
it  is  just  under  these  circumstances  that  the  subject  abandons 
himself  to  the  suggestive  use  of  stimulants,  such  as  coffee,  tea,  and . 

) 

i 


NEURASTHENIA 


657 


' liquors,  which  are  like  tinder  to  the  burning  fire  (Bianchi,  II 
iiervosismo  in  questa  fine  di  secolo,  1900).  In  the  acquired  forms  we 
must  take  especial  account  of  grave  diseases  of  infancy  and  of 
infectious  diseases,  but  above  all  of  influenza.  After  an  epidemic 
of  influenza  I observed  real  epidemics  of  neurasthenia,  some  of  the 
cases  recovering,  but  others,  in  predisposed  subjects,  being  much 
, more  refractory.  Malaria  is  not  less  pernicious  to  the  nervous 
system.  In  those  zones  where  there  is  intense  malaria  we  may  speak 
of  neurasthenia  as  endemic.  All  other  infectious  diseases  act  in 
the  same  way,  but  less  severely,  except  in  the  case  of  syphilis, 
which  has  a very  decisive  effect  (syphilitic  neurasthenia). 

The  bearing  and  suckling  of  numerous  children  cause  a very 
large  number  of  cases  of  neurasthenia  among  women  in  Italy,  and 
I particularly  in  the  South,  where  the  fecundity  is  excessive. 

I The  majority  of  cases  of  hypochondriacal  neurasthenia  amongst 
j women  of  both  the  lower  and  the  middle  classes  are  due  to  these 
j causes. 

Idleness  is  another  very  complex  cause  of  different  forms 
of  neurasthenia.  The  want  of  muscular  exercise  or  intellectual 
work,  and  consequently  of  that  high  tone  and  comfort  that  result 
from  the  accomplishment  of  work,  a life  passed  simply  in  vain 
attempts  to  kill  time,  and  the  instincts  that  take  the  upper  hand 
when  there  is  no  serviceable  work  to  be  done — onanism,  amours, 
alcoholism,  and  card-playing — are  some  factors  that  bring  about 
states  of  neurasthenia. 

To  all  this  there  must  frequently  be  added  the  economic  misery 
of  the  middle  classes  and  their  anxieties  for  their  very  numerous 
families.  Eight  times  out  of  ten  the  young  or  adult  men  who  come 
to  consult  me  from  distant  provinces,  especially  from  the  South, 
answer  my  inquiries  as  to  their  professions  or  vocations  in  a way 
that  moves  to  pity. 

‘ What  profession  do  you  carry  on  ?’  ‘ None.’  ‘ Trade  ?’ 

‘ None  ; I am  a landowner.’  ‘ Have  you  a large  estate  ?’  ‘ Small 

enough.’  ‘ Do  you  cultivate  it  yourself  ?’  ‘ No ; it  is  let.’  ‘ And 

what  do  you  do  ?’  ‘ Nothing  ; I find  things  to  do  in  the  housed 

In  these  few  words  we  have  condensed  all  the  habits  of  an 
asthenic,  miserable,  unproductive,  and  painful  life. 

I must  also  mention  briefly  two  other  cases  : intoxications  and 
traumata.  Intoxications  are  exogenous  and  endogenous.  The 
latter  will  not  take  any  effect  unless  the  subject  is  very  much 
weakened  or  predisposed  by  heredity.  We  must  pay  special 
attention  to  the  intestinal  toxic  products  and  to  arthritism.  Exo- 
genous intoxications  are  reduced  to  alcoholism  for  the  most  part, 
[but  to  a small  extent  they  are  due  also  to  the  products  of  combustion 
oi  carbon,  and  to  some  other  substances,  such  as  lead,  mercury, 
opium,  etc. 

Traumata  produce  both  general  and  partial  neurasthenias, 

42 


658 


PSYCHIATRY 


sometimes  of  a very  grave  order.  In  this  form  of  the  disease, 
topoalgia  (Blocq)  and  intellectual  deficiencies  are  particularly 
frequent,  but  simulation  and  suggestion  also  occur  very  often,  when 
questions  of  interest  to  the  subjects  are  involved,  as  in  the  case  of 
railway  accidents  or  accidents  connected  with  their  work. 

Prognosis. — Neurasthenia  is  a malady  per  se  (Moebius,  Biernacke, 
Binswanger),  or  it  is  a complexity  of  symptoms  (Charcot,  Gilles  de 
la  Tourette),  of  which  we  cannot  always  give  a good  prognosis. 
Neurasthenic  subjects  are  not  patients  who  always  recover  readily 
and  completely,  more  especially  as  they  cannot  always  attain  the 
conditions  favourable  to  their  recovery. 

It  is  only  the  slighter  forms  of  the  disease  that  are  certain  of 
recovery.  Syphilis  or  grave  neuropathic  heredity  aggravates  the 
prognosis.  It  is  certain  that  those  forms  of  neurasthenia  resulting 
from  work  which  the  individual  can  abandon  permit  of  a much 
happier  prognosis  than  those  other  forms  that  depend  upon  circum- 
stances from  which  the  poor  sufferer  cannot  escape.  It  is  an  easy 
matter  to  advise  a woman  to  try  not  to  have  any  more  children  ; 
it  does  not  take  long  to  tell  a lawyer  that  he  should  not  undertake 
any  more  cases,  or  to  say  to  a clerk  who  writes  a great  deal  that  he 
should  rest  his  weary  hand  ; but  when  it  becomes  a question  of  dying 
of  hunger  or  living  a wretched  life,  all  will  prefer  to  continue  working, 
and  that  is  the  principal  reason  why  there  are  so  few  recoveries. 

The  hereditary  form  is  more  serious  than  the  acquired,  and 
among  the  acquired  forms  the  most  obstinate  is  the  traumatic,  if 
we  compare  cases  that  are  identical  in  form  and  intensity. 

The  forms  of  neurasthenia  that  are  consequent  upon  intoxi- 
cation or  infection  are  not  so  serious  if  the  cause  can  be  removed. 

The  neurasthenia  of  adolescence  is  very  serious,  if  there  is  a 
hereditary  taint,  aggravated  by  onanism  and  by  the  abuse  of 
venereal  pleasures. 

Neurasthenia  in  women  during  the  period  of  lactation  generally 
ceases  or  is  alleviated  when  the  child  is  removed  from  the  breast. 

Periods  of  respite  may  occur  in  any  of  the  forms.  Many  cases 
in  which  there  is  anguish  end  in  suicide. 

Therapy. — The  therapy  is  aetiological  and  symptomatic.  Causes 
must  be  eliminated  wherever  possible ; abuse  of  any  kind, 
alcoholism,  arthritism,  intestinal  intoxications,  and  syphilis  should 
receive  special  attention  from  the  physician.  A rigid  course  of  life, 
sobriety,  and  muscular  energy  are  of  great  advantage.  I have 
seen  many  neurasthenic  young  men  recover  their  health  during 
military  service. 

The  symptomatic  treatment  varies  in  different  cases  according 
as  the  malad}’  is  erethistic  or  depressive.  The  oxygenated  air  of 
the  mountains,  well-regulated  muscular  exercises,  fattening  dietary 


NEURASTHENIA 


659 


for  anemic  or  emaciated  subjects  (Mitchell’s  treatment),  hydro- 
therapy, balneotherapy  in  its  different  forms,  and  electrotherapy 
(general  faradization  by  Rockwell’s  method,  galvanization  of  head 
and  spine,  galvano-faradization  and  franklinization)  may  prove  of 
great  advantage  in  skilled  hands. 

Cardiac  disorders,  gastric  and  intestinal  disturbances,  require 
the  most  varied  therapeutic  assistance,  but  this  is  not  the  place  to 
discourse  particularly  on  this  matter. 

The  crowd  of  much  vaunted  medicines  take  the  third  place. 
Neurasthenia  has  excited  the  hopes  of  a great  number  of  speculative 
chemists.  From  the  torpid  forms  that  require  excitants,  of  which 
the  chief  is  strychnine,  to  the  erethistic  forms  that  may  require 
bromide,  and  the  forms  with  anguish  that  benefit  by  opium,  there 
are  endless  series  of  medicines,  mixtures,  and  compositions,  that 
should  be  prescribed  only  by  a physician.  Where  there  is  a tendency 
to  suicide,  confinement  in  an  asylum,  at  all  times  advantageous, 
becomes  obligatory. 

In  many  cases  where  hysteria  enters  into  the  clinical  picture 
the  severe  but  encouraging  words  of  a physician  who  speaks  with 
authority  will  assist  more  than  anything  else.* 

* As  I have  had  to  restrict  to  a few  pages  my  notice  of  a subject  of  such 
importance  as  neurasthenia,  I refer  my  readers  to  the  best  monographs : 
Beard,  ‘Neurasthenia  or  Nervous  Exhaustion,’  New  York,  1880;  Axenfeld, 
Traite  des  Neuroses,  1883  ; Blocq,  La  Neurasthenia  etles  Neurasthe'niques,  1891  ; 
Bouveret,  La  Nenrasthe'nie,  1891  ; Levillain,  La  Neurasthe'nie,  1891  ; Mathieu, 
Neurasthenia,  1892  ; Binswanger,  Die  Pathologie  und  Therapie  der  N eurasthenie, 
1896;  Cappelletti,  La  Nevrastenia,  1903;  Carito,  La  Nevrastenia  e la  Vita 
Moderna,  1903. 


/ 


42—2 


CHAPTER  XI 


SEXUAL  PSYCHOPATHIES 

The  subject  of  anomalies  of  the  sexual  instinct  has  in  recent  years 
assumed  remarkable  proportions,  and  has  been  productive  of  a 
great  wealth  of  literature. 

For  the  comprehension  of  its  anomalies  we  must  consider  the 
sexual  instinct  from  the  point  of  view  of  its  evolutionary  history, 
both  phylogenetic  and  ontogenetic.  Regarding  them  from  the 
phylogenetic  as  well  as  the  purely  psychiatric  aspect,  we  would 
do  well  to  bear  in  mind  that  it  is  only  after  a long  and  gradual 
process  of  evolution  that  we  have  added  to  the  spinal  reflex 
phenomena  (vaso-motor)  the  instinctive  phenomena,  which  are 
the  synthesis  of  sensory  functions  engrafted  upon  the  organs  that 
flrst  fulfilled  exclusively  reflex  vaso-motor  functions. 

In  the  higher  animals  all  the  senses  tend  towards  the  constitu- 
tion of  what  we  call  sexual  instinct — touch,  smell,  taste,  sight, 
hearing.  Some  of  them — smell  and  taste— are  more  immediately 
connected  with  the  spinal  function,  whilst  others— sight  and 
hearing— favour  in  man  the  intellectual  part  of  the  instinct. 

The  intellectual  sesthetic  element  supervenes  only  in  the  truly 
evolved  man,  and  becomes  blended  with  the  instinct  properly 
so  tailed.  It  is  represented  by  the  sesthetic  sentiment,  and  the 
intellectual,  moral,  and  physical  sympathies  which  favour  the 
instinct,  and  hide  its  brutality  behind  the  elegant  curtains  with 
which  modern  love  screens  the  entrance  to  its  abode.  The  intel- 
lectual components  become  blended  with  the  instinctive  in  the 
same  way  as  the  latter  are  in  function  inseparable  from  the  funda- 
mental reflex  facts. 

We  must  bear  in  mind  that  during  intra-uterine  life  the  sexes 
are,  for  a certain  period  of  development,  not  differentiated.  Even 
after  the  sexual  form  is  well  defined,  psychic  and  instinctive  her- 
maphroditism continues  during  the  last  months  of  foetal  develop- 
ment and  during  the  years  of  infancy  and  childhood.  In  other 
words,  instinctive  and  psychic  hermaphroditism  persists  much 
longer  than  organic  hermaphroditism.  It  is  not  till  a much  later 
period  in  childlrood  that  we  can  detect  a certain  difference  in  the 
tendencies,  which  come  into  view  and  disappear,  just  like  the 

65o 


SEXUAL  PSYCHOPATHIES 


66i 


scouts  of  a slowly  advancing  army.  The  human  sexuality  is  well 
defined  at  the  age  of  adolescence.  It  is  apparent  that  here,  also, 
we  find  exemplified  the  common  law  that  phylogenesis  repeats 
itself  in  ontogenesis. 

Furthermore,  hermaphroditism  lies  latent  even  after  the  com- 
plete differentiation  of  the  sexes,  as  shown  by  the  phenomena  of 
regression  observed  in  castrated  individuals  and  in  the  ‘mujerados’ 
('La  Malattia  degli  Sciti,^  La  Psichiatria,  1885). 

Anomalies  of  the  sexual  instinct  always  occur  whenever  there 
is  a disturbance  of  the  evolutionary  equilibrium  of  the  various 
parts  whence  arises  love’s  complex  function,  this  disturbance 
leading  either  to  a defect  of  one  of  the  factors  of  the  function  or  to 
predominance  of  one  factor  over  the  others,  or  else  to  an  evolutionary 
error,  both  in  the  external  organs  and  in  the  nerve-centres  repre- 
senting them,  and  hence  we  find  a want  of  harmony  between  the 
organic  apparatus  and  the  sexual  tendencies.  All  the  anomalies, 
then,  connected  with  the  sexual  instinct  may  be  distinguished 
as  quantitative  and  qualitative.  Of  these  we  shall  make  a very 
rapid  review. 

The  quantitative  anomalies  are  divided  into  deficiencies  and 
excesses.  One  important  group  is  composed  of  males  showing 
sexual  arrest.  Physically  they  are  males,  but  the  penis  is  small 
and  the  testicles  small,  one  or  both  having  failed  to  descend  into 
the  scrotum.  Sometimes  they  are  beardless  ; some  are  slim  in 
figure,  and  exhibit  a sort  of  infantilism,  even  at  thirty  or  forty 
years  of  age  ; others  are  stout  and  pachy dermic  in  appearance. 
The  sexual  instinct  is  in  some  instances  entirely  absent,  while 
in  others  it  is  rudimentary  or  simply  intellectual,  like  a vague 
and  timorous  aspiration  after  woman.  I have  met  with  one  or 
two  such  who  were  relatively  more  evolved  and  capable  of  fecun- 
dating. Not  infrequently  we  find  disease  of  the  sperm  (Bianchi, 

‘ Degenerazione  grassa  dei  filamenti  spermatid, Mov.  Med.-chir., 
1876).  Frigidity,  proportionate  to  the  defective  evolution  of  the 
sexual  organs,  is  the  predominating  characteristic. 

As  a rule  they  are  feeble-minded,  but  I have  known  some  to 
be  vigorous,  wilful,  and  intellectual. 

The  woman  of  this  category,  like  the  man,  is  frigid,  and  may 
present  anomalies  of  the  sexual  apparatus — infantile  uterus, 
vaginal  septum,  etc.  She  is,  however,  very  difficult  to  distinguish 
from  the  more  evolved  woman,  and,  in  consequence,  is  able  to 
find  a husband,  whom  she  marries  for  social  reasons.  The  words 
of  Rochefoucaud  might  well  be  applied  to  this  category  : ‘ There 
are  persons  who  never  would  have  loved  had  they  not  heard  of 
love.’  It  is  important  to  remember  that  the  state  of  the  sexual 
organs  exerts  a great  influence  upon  the  instinct  ; in  some  cases, 
for  example,  the  frigidity  lasts  so  long  as  the  testicles  have  not 
descended  into  the  scrotum. 


662 


PSYCHIATRY 


In  the  woman  frigidity  is  associated  with  a disheartening  indiffer- 
ence, which  sometimes  leads  married  couples  to  consult  the  doctor. 
In  cases  of  this  class  it  is  supposed  that  with  the  deficient  develop- 
ment of  the  sexual  organs  there  is  a corresponding  evolutionary 
defect  of  the  nerve-centres. 

Again,  there  are  some  men  who  have  fully-developed  sexual 
organs,  and  are,  in  fact,  perfectly  constituted  and  developed,  pre- 
senting all  the  characteristics  of  the  male,  regarded  both  from  the 
physical  and  from  the  moral  and  intellectual  point  of  view,  who, 
nevertheless,  are  either  frigid  from  the  commencement  or  have 
become  so  after  a brief  period  of  onanism  at  the  epoch  of  adoles- 
cence or  of  youth.  They  have  no  desire  for,  and  feel  no  attraction 
towards,  the  opposite  sex  ; they  are,  as  a rule,  gloomy  and  solitary, 
and  seek  advice  and  treatment  from  the  doctor,  owing  to  these 
social  difficulties  and  the  consciousness  of  inferiority,  arising  from 
the  universal  consent  as  to  what  constitutes  a fully-developed  man. 

In  another  category  of  men  there  exists  a marked  disproportion 
between  the  sexual  appetite,  which  is,  I might  say,  rudimentary, 
and  the  intellectual  love,  which  is  comparatively  well  developed. 
These  individuals  are  the  excessive  platonists,  the  idealists  of 
love,  who  never  find  a person  of  the  opposite  sex  on  whom  to  rest 
their  desires.  Many  persons  of  both  sexes  who  are  subject  to 
erotic  paranoia  in  late  maturity  belong  to  this  category.  This 
erotic  idealism,  which  shows  itself  in  a mystic  aspiration  with 
vague  representation  of  the  sexual  life,  is  much  more  frequent  in 
woman  than  in  man. 

As  an  anomaly  of  excess,  I mention  the  great  prevalence  of 
erotic  images  and  ideas  that  almost  permanently  fill  the  conscious- 
ness of  certain  persons  who  seem  to  live  only  to  love.  This  preva- 
lence may  be  for  the  most  part  in  the  ideative  field,  and  the  indi- 
viduals are  passionate  idealists  ; it  may,  however,  affect  particularly 
the  instinctive  field,  in  which  case  the  subjects  abandon  themselves 
to  excesses  of  all  kinds,  finding  it  almost  absolutely  impossible 
to  change  their  mode  of  life  and  develop  new  tendencies  which 
might  modify  the  sexual  instinct  of  which  they  have  become  the 
slaves.  Men  and  women  alike,  they  are  in  most  instances  intel- 
lectual weaklings,  tainted  by  heredity  or  mentally  unbalanced. 
The  exuberance  of  the  sexual  instinct  is  detrimental  to  the  other 
mental  activities,  and  is  often  associated  with  hysteria  in  woman, 
neurasthenia  in  man. 

This  anomaly  is  frequent  in  some  countries  as  the  result  of 
historical  conditions  and  bad  training  ; sometimes  it  is  a manifes- 
tation of  a morbid  state  (paralytic  dementia  or  senile  dementia)  ; 
often,  however,  it  is  an  expression  of  sexual  nature  and  structure. 
Amongst  cases  I remember  is  that  of  an  unfortunate  man,  over 
fifty,  who  married  a woman  of  his  own  age,  a widow  for  the  third 
time.  He  had  hoped  to  live  in  peace,  but  was  doomed  to  dis- 


SEX  UA  L PS  Y CHOP  A TRIES 


653 


appointment,  fo';  serious  trouble  arose  very  early.  On  the  nuptial 
bed  the  woman  demanded  more  than  was  possible  of  a man  almost 
hfty-five.  When,  ruined  in  health,  he  came  to  consult  me,  the 
wife,  in  order  to  humiliate  the  husband,  who  attributed  his  weak- 
ness to  abuse,  unblushingly  accused  him  of  being  a good-for-nothing  ! 
That  woman,  even  at  her  advanced  age,  demanded  every  night  the 
sacrifice  to  Venus. 

As  regards  the  epoch  of  development  of  the  sexual  instinct,  it 
may  be  ver}^  late,  not  from  racial  reasons — as  in  the  peoples  of 
northern  countries — but  owing  to  retarded  evolution  (Ferrero, 
La  Eiiropa  Giovanc) ; in  other  instances,  as  in  neuropathic  sub- 
jects and  in  epileptics,  it  is  very  precocious  (vide  chapters  on 
delinquency  and  epilepsy). 

The  qualitative  disturbances  of  the  sexual  instinct  are  dis- 
tinguished as  inversions  and  perversions.  The  inversion  takes  the 
form  of  homo-sexual  tendencies  in  individuals  who  have  a more  or 
less  developed  and  recognisable  sexual  form.  These  are  divided 
into  two  sub-groups.  The  first  is  coxmposed  of  those  who  have 
sexual  organs  not  well  developed  (more  demonstrable  in  the  male), 
and  who,  if  males,  present  many  features  of  femininity,  if  females, 
many  features  of  masculinity  ; thus  we  may  have  an  inverted 
female-form,  and,  vice  versa,  an  inverted  male-form.  The  second 
group  comprises  individuals  who  present  a regular  development 
of  the  sexual  organs  and  of  the  external  bodily  forms  proper  to 
their  sex,  yet  have  homo-sexual  tendencies  like  the  members  of 
the  first  group. 

An  example  of  the  first  group  may  be  briefly  described  as  follows  : 
A.  B.,  male,  beardless,  sexual  organs  not  well  developed,  two  small 
testicles  in  a small  scrotum,  hair  only  on  pubis,  hair  of  head  long, 
being  cut  only  at  level  of  shoulders,  aquiline  nose,  light-blue  eyes, 
tumid  lips,  large  mouth,  rounded  form,  large  feminine  pelvis,  well 
developed  breasts,  abundant  adipose  tissue.  He  goes  about  with 
bare  head,  like  the  women  of  the  district.  He  has  never  been 
capable  of  receiving  the  education  of  a male,  but  has  learned  to 
sew  and  to  do  embroidery.  He  belongs  to  a family  with  a history 
of  insanity  and  alcoholism.  Women  are  absolutely  repugnant  to 
him,  but  in  the  courtyard  of  his  house,  after  dark,  he  is  the  constant 
convenience  of  a succession  of  male  lovers.  These  latter  may  also 
be  numbered  amongst  the  sexually  inverted — the  podophils.  It 
is  difficult,  however,  to  pronounce  judgment  upon  them,  as  we 
shall  see  a little  further  on  when  we  come  to  speak  of  pederasty. 

Corresponding  to  the  inverted  female-form  we  have  to  consider 
the  inverted  male -form,  with  narrow  pelvis,  active,  muscular 
limbs,  hair  on  the  face  and  on  the  limbs,  and  sometimes  with  long 
and  erectile  clitoris.  To  her  man  is  repugnant.  She  prefers  to 
dress  as  a man  ; si  e has  a bold  appearance  ; she  loves  and  delights 
in  woman.  As  a rule,  she  overcomes  an  exceedingly  weak  type  of 


664 


PSYCHIATRY 


woman,  who  yields  to  the  love  of  the  virago.  Sometimes  she  fre- 
quents brothels  in  order  to  give  vent  to  her  prepotent  instinct  for 
woman . 

Inverted  female-forms  and  inverted  male-forms  both  present 
many  degenerative  stigm.ata  and  many  physical  characteristics 
of  the  opposite  sex.  They  usually  belong  to  families  hea^dl3^ 
burdened  with  hereditary  taint. 

The  strong  type  of  man  (inverted  podophil)  who  yields  to 
the  invitation  of  the  male  female-form  and  the  exceedingly  weak 
woman  who  succumbs  to  the  love  of  the  female  male-form,  may 
show  physical  and  psychical  signs  of  degeneration,  but  these  in 
most  instances  are  not  very  marked.  We  miay  also  meet  with 
occasional  inverted  individuals. 

Those  of  the  second  group  who  have  inverted  instincts  without 
corresponding  sexual  and  bodily  forms  are  also,  as  a rule,  afflicted 
with  hereditary  taint,  but  in  a less  degree  than  the  others.  Of  two 
individuals  who  form  a hom.o-sexual  union  the  more  degenerate 
is,  in  the  case  of  men,  the  passive,  in  the  case  of  women,  the  active. 

In  a separate  group  should  be  classed  those  active  inverts  who, 
differing  fromi  the  occasional  inverts,  feel  no  attraction  towards 
woman,  and  can  only  love  persons  of  their  own  sex.  Such  cases, 
if  we  exclude  those  that  are  perversions  consequent  upon  habit, 
are  rather  rare.  An  occasional  invert  may  from  habit  become 
a professional  pervert ; he  may  also  have  an  offspring  in  wfflom 
antipathic  sexual  instinct  (inversion)  is  present  ah  origine. 

Next  we  have  the  indifferent,  who  love  m^ales  and  females 
equally,  according  to  the  environment  they  happen  to  be  in. 

The  inverted  female-forms  present,  in  addition,  other  peculiar- 
ities and  differences.  Some  are  platonists.  They  have  an  ideal 
love  for  the  male  sex,  they  are  romantic  in  their  attitudes,  and  are 
often  the  protagonists  of  the  romances  of  sexual  perversion. 
Others,  according  to  Laurent,  Luyt,  Moll,  are  true  representatives 
of  passivism  ; they  are  poor-spirited,  mean,  given  to  the  most 
debasing  and  injurious  conduct  one  can  imagine  of  a man.  Such 
conduct  ma}^  be  met  with  even  in  women,  as  the  result  of  habit 
(development  of  tactile  sensibilit}^  through  exercise).  In  this 
case  we  may  speak  of  perversion  rather  than  inversion. 

In  my  opinion,  pederast^^  apart  from  the  cases  of  true  inversion, 
is  more  a perversion  than  an  inversion.  Wherever  men  who  have 
not  been  accustomed  to  control  their  instincts  are  gathered  together 
under  conditions  where  it  is  impossible  to  gratify  their  sexual 
desires  (military  camps,  colonies,  prisons,  colleges)  we  find  the 
strong  types  imposing  on  the  weaklings,  the  latter  yielding  to 
the  desires  of  the  former.  The  majorit}"  assume  normal  habits 
once  the  particular  conditions  of  existence  are  at  an  end.  Pre- 
disposed individuals  may  become  perverts,  active  or  passive.  Active 
pederasts  have  a preference  for  3’ouths  of  feminine  appearance. 


SEXUAL  PSYCHOPATHIES  665 

and  may  also  have  relations  with  women.  There  is  often  a brutish 
instinct  present. 

From  these  types  we  have  to  distinguish  those  in  which  the 
subjects  are  conscious  of  the  inversion  and  struggle  against  it, 
with  all  their  power,  so  as  to  avoid  experiencing  the  shame  attached 
to  the  acts  towards  which  they  feel  themselves  forcibly  drawn. 
Amongst  these  we  find  both  active  and  passive  types.  Here  is 
the  substance  of  one  of  several  consultations  : ‘ I seek  your  advice 
in  tiie  hope  that  you  may  save  me  from  a position  of  the  cruellest 
Pind— a position  that  threatens  to  compromise  my  dignity  and 
the  honour  of  my  family,  and  against  which  I have  struggled  from 
my  youth  upwards.  I have  tried  to  find  pleasure  in  intercom  se 
with  woman,  but  I feel  no  passion  for  her,  although  I am  able  to 
fulfil  the  act  of  coitus  regularly  ; I have,  on  the  other  hand,  a 
violent  love  and  desire  for  man.  Prescribe  something  that  will 
liberate  me  from  this  obsession.’  That  is  a case  of  sexual  inversion 
in  a person  m.orally  and  physically  a male. 

Another  case  is  as  follows : A teacher  came  from  a distant 
province  to  consult  me  because  for  about  ten  years,  during  which 
time  he  had  been  teaching,  he  had  felt  a strong  attraction  towards 
the  school- children,  but  had  always  been  fully  conscious  of  his 
position  as  instructor,  and  had  retained  great  command  of  himself. 
Arrived  at  the  age  of  thirty-six,  he  was  irresistibly  led,  by  the 
prepotency  of  his  perverted  instinct,  to  satisfaction,  and,  alarmed 
at  an  act  contrary  to  moral  and  civil  law,  came  to  seek  my  advice. 
That  is  a case  of  sexual  inversion  with  obsession. 

In  those  cases  we  have  examples  of  mild  forms  of  sexual  inver- 
sion, with  fairly  complete  development  of  the  intelligence,  so  that 
the  anomaly  is  noticed  by  the  consciousness,  and  the  dangers 
attached  to  abandonment  to  the  suggestion  of  the  inverted  instinct 
are  fully  appreciated. 

The  malady  resembles  in  its  manifestations  the  fixed  idea 
or  the  coactive  impulse.  The  subjects  are  at  bottom  evolved 
inverts,  or  perverts. 

The  same  condition  may  occur  through  masturbation.  There 
are  men  accustomed  to  masturbation  from  youth,  who,  though 
capable  of  fulfilling  regular  coitus,  prefer  to  masturbate  alongside 
the  woman,  rather  than  have  regular  intercourse  with  her.  Amongst 
these  are  husbands  who,  sometimes  from  the  very  first  day  of 
matrimony,  have  obliged  the  wife  to  witness  the  degrading  and 
repugnant  spectacle. 

In  women  also  do  we  sometimes  observe  an  insuperaole  repug- 
nance to  copulation.  Quite  recently  I saw  a young  woman,  who, 
during  the  two  years  of  her  married  life,  had  never  wished  to  have 
intercourse  with  her  husband,  whom  yet  she  loved,  and  always  had 
loved,  intellectually  and  ardently.  She  had  such  a repugnance  for 
copulation  that  at  every  attempt  of  the  husband  she  was  seized  by 


666 


PSYCHIATRY 


an  inexpressible  fear,  accompanied  by  cries,  cold  sweats,  trembling 
and  vomiting,  and  no  treatment  was  successful  in  producing 
amelioration.  She  was  a well-formed  woman,  judging  from  external 
appearances.  After  two  years  of  futile  attempts  the  husband 
instituted  legal  proceedings  for  divorce. 

Other  not  uncommon  forms  of  sexual  perversion  are  bestiality, 
necrophily,  and  sadism. 

Bestiality  is  the  copulation  of  man  with  domestic  animals — j 
dogs,  ruminants,  and  solipeds.  This  condition  was  known  to  i 
antiquity  ; it  is  frequent  amongst  uncultured  people  living  in  tlie 
country  — for  instance,  among  cowherds,  who  not  infrequently 
have  their  special  heifer  or  cow.  Bestiality  is  not  rare  in  childhood 
at  the  dawn  of  the  prematurely  developed  sexual  instinct.  In 
most  instances  the  perversion  is  determined  by  an  impression  pre- 
viously received — assisting  at  the  copulation  of  dogs,  horses,  cattle, 
and  goats  in  the  solitude  of  the  country — which  excites  imitative 
acts,  often  through  want  of  other  means  of  satisfying  the  instinct 
thus  excited.  Even  children  sometimes  abandon  themselves  to 
such  actions  after  having  witnessed  the  copulation  of  dogs  in  the 
public  thoroughfares,  and  sometimes  in  their  own  homes.  The 
instinct  thus  awakened  is  ver\^  plastic,  and,  the  first  pleasurable 
act  fulfilled,  repetition  comes  of  itself,  by  force  of  association, 
especially  in  neuropaths  in  whom  there  is  a defect  in  the  power 
of  resistance  to  this  perverted  instinct,  and  in  whom  there  are  not 
yet  evolved  the  other  normal  factors  of  the  sexual  instinct  and  of 
love  which  will  lead  to  atrophy  of  the  perverted  habit. 

Necrophily  consists  in  the  satisfaction  of  the  sexual  instinct 
on  the  cadaver.  In  such  cases  we  have  to  deal  with  epileptic 
impulses,  true  epileptic  equivalents,  or  with  imperative  ideas 
accompanied  by  emotions  and  perversions.  While  bestiality  may 
— at  least,  in  its  commencement  — be  considered  an  imitative 
or  an  occasional  physiological  fact,  like  pederasty  in  prisons, 
colonies,  etc.,  necrophily  must  always  be  regarded  as  a pathological 
fact  occurring  in  natures  heavily  burdened  with  hereditary  taint, 
and  in  some  way  or  other  arrested  in  their  mental  development 
(imbeciles,  epileptics,  obsessed). 

Sadism,  or  cruelty  in  love,  is  also  a phenomenon  of  reversion, 
according  to  the  lucid  interpretation  of  Penta,  who,  in  Vincenz  Verzeni 
(a  strangler  of  women)  gives  one  of  the  most  memorable  examples, 
and  finds  material  for  a very  instructive  book  (/  pervertimenti 
scssuali  ncir  uomo,  etc.,  1893). 

Sadism  presents  various  degrees  up  to  anthropophagy,  which 
is  the  non  plus  ultra  of  ferocity  and  monstrosity  in  the  sexual  act. 
Just  as  the  male  wolf  of  the  desert,  in  the  violence  of  his  amorous 
assault,  bites  and  kills  not  only  his  rivals,  but  also  the  female,  and 
as  the  male  toad  euibraces  the  female  so  energetically  that  the 
fingers  penetrate  the  skin  and  sometimes  even  cause  death  from 


SEXUAL  PSYCHOPATHIES 


667 


suffocation,  so  man  sometimes,  unconscious  of  all  but  his  passion, 
impulsive  and  ferocious,  becomes  anthropophagic  in  his  love ; or 
the  perversion  and  ferocity  may  reach  such  a point  as  to  be  capable 
of  finding  satisfaction  of  the  instinct  in  the  warm  viscera  of  the 
murdered  woman. 

Sadism  may  be  active  or  passive.  The  active  form  manifests 
itself  in  maltreatment  or  mutilation  of  the  victim  during  the 
sexual  act. 

The  passive  form  is  also  known  by  the  name  masochism, 
and  consists  in  maltreatment,  which  the  man,  voluntarily  and  by 
invitation,  undergoes  at  the  hands  of  the  woman  befoie  fulfilling 
the  act,  and  which  sometimes  is  even  substituted  for  the  act  itself. 
Some  beat  themselves  on  the  nates  and  on  the  chest  even  to  bruising  ; 
others  make  the  woman  sit  on  and  compress  their  chest  ; whilst 
others,  again,  require  to  be  beaten  to  the  efiusion  of  blood  in  order 
to  provoke  the  erection. 

Sometimes  the  entire  satisfaction  of  the  instinct  consists  in 
these  maltreatments.  A well-known  case  is  that  of  an  impotent 
man  who  every  week  visited  a brothel,  and  invited  two  or  three 
women  to  stamp  on  his  chest  and  face  with  shoes  on  their  feet, 
after  which  he  paid  them  and  went  his  way,  satisfied. 

Another  form  of  perversion  consists  in  sexual  fetishism.  There 
we  have  to  do  with  individuals  who  are  less  excited  by  normal 
relations  with  the  opposite  sex  than  by  some  object  which  has 
belonged  to  them,  and  which  first  provoked  an  unusual  sexual 
pleasure  ; thus,  for  example,  one  man  is  excited  at  the  sight  of  a 
hat,  another  by  a nightshirt  (Magnan,  Charcot),  another  by  a slipper, 
another  bv  shoes.  Whilst  the  female  j)er  se  offers  little  or  no 
attraction  to  these  individuals,  such  trifles ^cite  them  even  to 
the  complete  satisfaction  of  their  instinct  (erection,  ejaculation).* 

From  true  sexual  fetishism  there  is  distinguished  amor  syne- 
dochicus  (synedochique.  Fere),  consisting  in  the  love  aroused  by 
a part  of  the  body,  by  the  clothing,  or  by  a moral  or  intellectual 
quality  of  an  individual  of  the  opposite  sex.  Since  this  particular 
part  or  quality  is  associated  in  the  mind  with  an  ideal  type  which 
does  not  correspond  with  reality,  it  happens  that,  whilst  the  amorous 
individual  of  this  kind  cannot  abandon  his  victim,  he  does  not 
pardon  all  the  many  defects  which  he  finds  in  the  latter  as  com- 
pared with  the  ideal  that  he  has  formed  for  himself. 

* The  reader  who  desires  further  particulars  should  consult  Krafft-Ebing, 
Psychopathia  Sexualis Tarnovski,  Die  Kvankhaften  Erscheinungen  des 
geschlechts  Sinnes : Schrenck-Notzing,  ‘Suggestive  Therapeutics  in  Psycho- 
pathia Sexualis  Moll,  Contvaire  Sexualempfindung  Penta,  op.  cit.  . Mante- 
gazza,  Gli  amovi  degli  uoinini ; Lombroso,  several  articles  in  his  Archives ; 
Fere,  La  Pathologie  des  Emotions ; Morton  Prince,  ‘ Sexual  Perversion  or  Vice 
{Journal  of  Nervous  and  Mental  Disease)  ; Laupts,  Perversion  et  Perversitc 
Sexuales;  Havelock-Ellis,  ‘Studies  in  the  Psychology  of  Sex— Sexual 
Inversion.’ 


668 


PSYCHIATRY 


Amongst  masochists  and  fetishists  we  may  group  those  whose] 
perversion  is  still  more  degrading,  and  who  excite  themselves  by| 
the  urine  of  the  female,  even  drinking  it  or  swallowing  other  filth 
(cases  of  Cantarano).  ! 

1 

/Etiology. — The  gravest  forms  of  sexual  perversion  are  cer- ' 
tainly  the  expression  of  a morbidity  of  the  nervous  system.  In 
these  cases  we  have  almost  always  to  deal  with  an  inherited  neuro- ; 
pathic  and  psychopathic  constitution.  The  inversion — that  is  to 
say,  the  error — in  the  nervous  system  of  a woman  whose  body  is 
masculine,  and  vice  versa  (Magnan,  Gley),  is  undoubtedly  a con-  | 
genital  condition.  This  statement  is  especially  confirmed  by  those 
inverted  males  or  females  who  have  some  of  the  bodily  features 
of  the  opposite  sex.  We  may  hold  that  in  these  cases  either  the 
embryonal  hermaphroditism  is  transformed  into  more  or  less  com- 
plete somatic  mono-sexuality,  but  with  an  opposite  psychic  mono- 
sexuality remaining,  or  at  a somewhat  more  advanced  stage  it 
stops  at  psycho-sensory  hermaphroditism. 

From  this  point  of  view,  and  looking  to  this  single  category 
of  cases,  I fall  in  with  Krafft-Ebing,  Moll,  Kiernan,  Chaddock, 
Lydston,  Penta,  and  others,  who  hold  more  or  less  the  congenital  .j 
nature  of  the  sexual  instinct.  This  hypothesis  is  not  applicable 
to  all  cases.  Most  of  the  other  forms  of  perversion  owe  their  origin  , 
to  an  occasional  factor,  which,  given  the  neuropathic  constitution ; 
of  the  subjects,  and  hence  a less  degree  of  resistance,  gives  rise  to 
the  habit,  and  with  the  habit  comes  the  perversion.  The  cases  ! 
of  fetishism,  for  example,  have  been  in  great  part  of  occasional ' 
origin  in  eminently  neuropathic  individuals.  Sometimes  heredity 
is  reinforced  in  the  sense  that  an  occasional  abnormal  inclination 
may  in  the  offspring  become  an  organized  and  fixed  manifestation.  ! 
The  doctrine  of  acquisition  is  upheld  by  many,  amongst  them  ( 
Laupts,  Schrenck-Notzing,  Binet,  and  Havelock-Ellis.  The  pre-  : 
vailing  notion  is  that  occasional  impressions  excite  desires  and  i 
lead  to  acts,  these  in  turn  giving  rise  to  sensations  and  ideas  which  j 
become  imperative.  Pleasure  and  the  means  of  attaining  it  are 
two  indissoluble  elements,  and,  when  the  mind  is  filled  with  thoughts 
of  pleasure,  it  is  difficult  to  decompose  that  psychic  product  so 
as  to  obtain  from  it  a more  normal  compound.  This  is  possible 
only  in  the  most  fully-evolved  natures.  ! 

Pederasty,  like  bestiality,  is  almost  always  the  result  of  circum-  | 
stances.  The  amorous  inclination  for  youths  arises  in  the  adult  i 
from  the  sight  of  forms  not  perfectly  differentiated,  as  is  often  found  | 
in  youth  (examples  : Alfieri,  Rosseau).  In  some  neuropaths  the 
impulse  and  tendency  to  indulge  in  love  with  youths  become 
obsessions.  i\Iasochism  is  often  an  unconscious  adaptation  by  im- 
potent individuals  to  an  intensification  of  the  tactile  stimuli,  by  I 
means  of  painful  stimuli,  in  order  to  attain  the  end  of  copulation,  i 


SEXUAL  PSYCHOPATHIES 


669 


Heredity  almost  invariably  plays  a part,  often  giving  rise  to  a 
similar  anomaly,  which  in  the  offspring  is  reinforced.  The  sexually 
weak  father  begets  the  son  similarly  weak,  frigid  (psychic  herma- 
phroditism), or  inverted.  Weak  mental  development,  feeble  power 
of  resistance  to  momentary  impulses,  which  tend  to  become  fixed, 
explain  all  the  other  phenomena. 

In  many  of  these  cases  where  the  sexual  organs  are  well  formed 
we  get  an  anomalous  testicular  secretion,  with  absence,  scarcity, 
small  size,  or  fatty  degeneration  of  the  nemasperms  (Bianchi, 
La  degenerazione  gvassa  dei  filamenti  spermatid,  1876).  The 
nature  of  this  work  does  not  allow  me  to  enter  into  fuller  details 
concerning  this  matter.  The  subject  is  one  requiring  more  accurate 
examination,  and  a larger  number  of  observations  than  have 
hitherto  been  made.  In  this  respect  it  has  been  somewhat  neglected. 

The  prognosis  varies  in  different  cases.  Inverts  with  somatic 
characteristics  of  the  opposite  sex  are  incurable  ; psychic  inverts 
with  regularly  developed  organs  are  more  hopeful. 

Defects  of  development  manifest  in  the  organs  are  almost 
incurable.  Frigidity  may  be  modified  by  appropriate  treatment 
along  with  exercise.  Sadism  comes  under  the  domain  of  the  penal 
code  or  of  the  asylum,  as  do  also  anthropophagy  and  necrophily. 
It  is  a difficult  matter  to  find  the  time  and  the  means  to  treat  them. 

The  coactive  impulses  come  under  the  study  of  fixed  or  imperative 
ideas. 

Therapy.  — To  improve  the  functional  tone  of  the  nervous 
system,  to  strengthen  the  predisposed  physically  and  psychically, 
is  the  chief  and  fundamental  duty  of  the  physician,  who  must  also 
impress  on  public  administrators  the  necessity  of  adopting  strict 
measures  to  prevent  children  receiving  impressions  that  prematurely 
arouse  and  pervert  the  sexual  instinct.  He  must  strive  to  cure 
impotence,  which  is  the  instigator  of  a number  of  methods  that 
give  rise  to  perversions.  Education  to  a more  normal  sexual  life, 
conducted  on  strict  lines  that,  in  cases  not  really  congenital,  break 
the  old  and  create  new  habits,  has  in  several  cases  given  me  satis- 
factory results.  Suggestion,  recommended  by  Morton  Prince  and 
other  authorities,  may  give  like  results  in  the  case  of  fixed  ideas. 
The  best  form  of  suggestion  is  that  coming  from  persons  who  can 
exercise  authority,  and  especially  from  the  doctor,  when  the  cir- 
cumstances permit  its  association  with  sexual  re-education. 


CHAPTER  XII 


SECOND  GROUP— GENERAL  CONSIDERATIONS 

I HAVE  already  referred  to  the  pathological  conception  and  given 
the  basis  of  this  second  group  (Part  IIP,  Chapter  IL).  The  diseases 
herein  included  are  produced  through  the  entrance  into  the  blood 
of  endogenous  or  exogenous  toxic  substances  which  are  of  bacterial 
origin,  or  due  either  to  anomalous  chemical  products  of  the  tissue 
metabolism  or  to  abnormal  intestinal  fermentations.  Some  of  the 
diseases  of  the  hrst  group  are  likewise  of  toxic  origin.  It  is  sufbcient 
to  recall  here  myxoedematous  idiocy  and  infantile  encephalitis 
(whence  arise  the  already  studied  forms  of  phrenasthenia),  the  . 
abundant  literature  dealing  with  the  toxic  genesis  of  epilepsy—, 
literature,  however,  which  leaves  in  our  minds  a great  many  doubts  ;| 
—also  the  hereditary  toxic  genesis  of  the  majority  of  the  diseases  of 
the  first  group,  such  as  alcoholism  in  the  parents,  infectious  diseases 
of  the  mother  during  gestation,  syphilis,  tuberculosis,  etc.,  as  demon-  J 
strated  by  the  experimental  researches  of  Maffucci,  Fere,  and  Ceni.  ' 

We  have  also  indicated  the  reasons  which  induced  us  to  dis-  ' 
tinguish  the  diseases  of  the  first  group  (of  possible  hereditary 
toxic  genesis)  from  those  of  the  second  group  (of  direct  toxic  or  ^ 
infective  genesis).  The  febrile  deliria,  which  are  sometimes  con-  ( 
tinned  under  the  form  of  psychoses  ; the  psychoses  and  neuroses  I 
that  occur  as  sequelae  of  influenza  (very  frequent),  typhus,  small-  i 
pox,  etc.  ; the  psychoses  arising  from  intestinal  intoxications  and  ] 
coprostasis  in  the  same  way  as  encephalitis,  acute  myelitis  and 
neuritis,  now  shown  to  be  of  toxic  or  bacterial  origin,  likewise 
the  results  of  all  the  researches  made  on  the  blood  and  the  urine 
of  those  patients  (increased  toxicity)  ; the  frequent  presence  of 
micro-organisms  in  the  blood  of  the  acutely  insane  ; the  resemblance 
of  these  psychoses  to  those  of  exogenous  intoxication  due,  e.g., 
to  alcohol,  sulphide  of  carbon,  morphine,  cocaine,  etc. — all  these 
go  to  demonstrate  the  rationality  of  the  differentiation  of  this 
group  from  the  first,  a differentiation  equally  rational  from  the 
^etiological  point  of  view. 

W hilst  in  the  first  group  the  disease  lies  in  the  psycho-phvsical 
structure  of  the  individual  and  of  the  family,  in  the  second  it  is  j 
imported  by  an  extrinsic  or  intrinsic  factor  always  toxic  in  nature.  ! 

670  j 


SECOND  GROUP— GENERAL  CONSIDERATIONS  671 


It  is  well  to  note  that  the  diseases  of  the  second  group  general!}^ 
affect  those  who  present  a significant  cerebral  vulnerability,  usually 
hereditary.  It  serves  no  useful  purpose,  either  from  a practical 
or  from  a purely  theoretical  point  of  view,  to  distinguish  the  diseases 
of  this  group  as  degenerative  psychoneuroses  and  psychoses.  This 
distinction  has  now  served  its  day,  and  incurability^  cannot  be 
employed  as  the  basis  of  a rational  distinction.  Acute  dementia 
may  be  followed  by  recovery,  or  it  may  take  on  all  the  features 
of  dementia  prsecox,  apart  altogether  from  the  nature  of  the  soil 
in  which  it  is  developed,  and  that  we  may  not  know.  Exposed  to 
the  action  of  exogenous  or  endogenous  intoxications,  well-developed 
brains,  as  well  as  those  not  perfectly  developed,  are  vulnerable. 
Thus  it  is  that  many  hereditarily  weak-minded  individuals  are 
subject  to  the  acute  diseases  of  this  group,  inasmuch  as  their  brains 
are  more  readily  affected  by  the  action  of  toxic  substances  ; in  this 
respect,  however,  they  differ  in  no  way  from  men  well  developed 
in  body  and  mind  but  with  a hereditary  taint.  In  other  words, 
their  brains  exercise  a much  less  destructive  and  phagocytic  power 
over  the  toxic  substances  which  find  their  way  into  the  blood  ; 
the  histo-chemical  structure  of  their  nervous  elements  is  less  resist- 
ing, or,  in  other  words,  the  chemical  substances  composing  the 
nerve-elements  show  greater  affinity  for  the  toxic  substances. 

Imbeciles  and  those  of  defective  evolution  subject  to  these 
acute  forms  of  curable  and  incurable  psychosis  are  very  numerous, 
but  that  does  not  detract  from  the  fact  that,  in  their  clinical  aspects, 
these  psychoses  may,  from  their  origin,  evolution,  and  issue,  possess 
characters  so  very  salient  as  to  justify  their  being  grouped  together, 
their  precise  aetiological  indication  determining  also  a more  rational 
therapeutic  treatment. 

It  is  therefore  worth  while  recalling  attention  to  the  fact  that, 
whilst  the  common  infective  diseases  present  a well-defined  clinical 
form  with  respect  to  the  pathogenic  agent,  so  that  we  have  a con- 
siderable knowledge  of  the  micro-organisms  and  the  toxines  of  enteric 
fever,  small-pox,  plague,  and  diphtheria,  etc.,  this  particular  is 
completely  awanting  in  acute  mental  affections.  The  same  toxine 
may  produce  very  different  forms  of  psychosis.  Just  as  acute 
alcoholic  intoxication  may  produce  exhilaration  in  one  person, 
sullenness,  melancholia,  and  weeping  in  another,  or  induce  motor 
inco-ordination  or  staggering  in  a third,  and  headache  in  a fourth, 
so  may  all  the  other  toxines  behave.  The  same  toxic  properties  of 
the  urine  and  of  the  blood  serum,  and  the  presence  of  the  same  micro- 
organismis  in  the  blood,  coincide  often  with  the  most  diverse  forms  of 
acute  insanity.  Here  the  individual  factor  is  to  be  reckoned  with. 

I am  well  aware  that  some,  such  as  Ceni,  do  not  think  thus.  Fol- 
lowing upon  a certain  number  of  observations,  in  which  he  found 
a fairly  large  numiber  of  the  more  common  varieties  of  micro- 
organisms (Streptococcus  pyogenes,  Staphylococcus  aurea,  Bacillus 


672 


PSYCHIATRY 


coli,  and  others)  in  the  blood  of  several  patients  suffering  from  acute 
psychoses  belonging  to  the  group  with  which  we  are  dealing,  not- 
withstanding that  their  presence  coincides  with  an  aggravation 
of  the  psychosis  and  their  disappearance  with  an  improvement, 
Ceni  has  believed  himself  warranted  in  concluding  that  pre- 
existing psychosis  diminishes  the  phagocytic  power  of  the  blood 
and  the  tissues,  and  permits  the  entrance  into  the  blood  of  these 
micro-organisms  which  would  only  induce  an  aggravation,  an 
acute  episode  of  the  primary  psychosis. 

Regis  has  taken  a clearer  and  wider  view  of  the  matter  ('Auto- 
intoxications ct  delires — Psychoses  d' auto-intoxications  : considera- 
tions generates,'  Brochure  et  Aj.r chives  de  Nevrologie,  1899) ; so  also 
has  Ford  Robertson  (‘The  Role  of  Toxic  Action  in  the  Patho- 
genesis of  Insanity,’  British  Medical  Journal,  1901).  The  French 
author  attaches  less  importance  to  infections  and  too  great  impor- 
tance to  auto-intoxications,  as  observed  in  deliria  from  renal,  hepatic, 
and  gastric  intoxications,  etc.,  whilst  the  very  competent  pathologist 
of  the  Scottish  asylums  brings  forward  interesting  material  with 
regard  to  observations  of  great  value  for  the  solution  of  the  grave 
problem.  However  it  may  be,  aud  with  due  reservations  respecting 
the  relations  between  the  genesis  of  insanity  and  the  primary 
cause  determining  it,  the  fact  remains  that  from  all  sources 
fresh  confirmation  is  being  received  every  day  that  the  group  of 
diseases  with  which  we  are  dealing  is  of  toxic  origin. 

When  we  consider  that  the  brain  is  a mechanism  ot  marvellous 
complexity,  the  aggregate  of  a very  great  number  of  organs  which  ■ 
do  not  all  attain  the  same  degree  of  harmonious  perfection,  nor  ! 
enjoy  the  same  power  of  resistance,  we  can  well  imagine  the  great 
variety  of  clinical  forms  arising  from  pathogenic  agents  which 
injure  one  more  than  another  of  the  cerebral  organs  ; and  this  fact  , 
also  corresponds  to  the  predominance  of  certain  psychic  com-  . 
ponents  which  give  to  the  structure  of  each  personality  the  j 
stamp  of  individual  character.  It  is  for  a like  reason  that  poly-  \ 
neuritis  is,  in  many  cases,  not  accompanied  by  mental  disturbances,  ■ 
while  in  others  there  is  produced  the  form  of  psychosis  described  < 
under  the  name  of  polyneuritic  psychosis,  and  that  influenza  pro- 
duces in  one  melancholia,  in  another  mania,  in  a third  sensory 
delirium,  and  in  a fourth  polyneuritis. 

Summing  up  all  tlie  preceding  arguments,  we  may  say  that, 
with  regard  to  the  diseases  of  this  group,  it  is  impossible  to  speak 
with  the  strictest  accuracy  of  a definitely  established  relation 
between  nosological  form  and  specificity  of  the  pathogenic  agent. 

The  literature  of  the  subject,  especially  the  Italian,  is  so  rich  in 
facts  that  it  would  be  useless  labour  to  relate  here  even  a few  of  them. 
The  sjflendid  and  full  report  by  Professors  d’  Abundo  and  Agostini 
to  the  Congress  of  Italian  Phreniatrists,  held  at  Naples  in  October, 
1899,  advantageously  consulted  in  regard  to  the  subject. 


CHAPTER  XIII 


MANIA 

Some  authors,  following  the  views  and  classification  of  Kraepelin, 
would  include  melancholia  and  mania,  as  well  as  the  periodical  and 
circular  forms  of  these  psychoses,  under  one  denomination,  and 
regard  them  as  different  forms  of  one  morbid  entity,  to  which  the 
name  of  maniacal-depressive  insanity  has  been  given.  According 
to  Kraepelin,  melancholia  and  mania  are  gradations  of  the  same 
disease.  This  manner  of  looking  at  the  subject  is,  in  appearance, 
justified  by  the  facts  that  melancholia  is  often  preceded  or  fol- 
lowed by  a short  or  a long  phase  of  exaltation  ; that  mania  is  very 
often  preceded  and  also  followed  by  a phase  of  melancholia  ; 
that  in  many  cases  the  attack  consists  of  a period  of  melancholia 
lasting  for  months  or  years,  followed  by  a maniacal  period,  also 
of  months’  or  years’  duration,  and  vice  versa  ; that  an  attack 
of  melancholia  or  mania  may  be  followed  after  four,  six,  or  more 
years  by  an  attack  of  an  opposite  form  ; that,  in  short,  the  circular 
form  of  this  psychosis  goes  to  demonstrate  the  tendency  to  both 
depression  and  exaltation  in  the  same  patients,  and  hence  the 
reason  for  including  the  various  syndromes  in  one  single  patho^ 
logical  conception  which  may  embrace  them  all,  and  in  a single 
clinical  picture,  with  its  nosological  varieties.  Nevertheless,  long  and 
close  observation  of  patients  for  decennaries  on  end  demonstrates 
undeniably  that,  besides  all  the  clinical  forms  indicated  above, 
there  do  exist  cases  of  pure  mania  and  pure  melancholia,  which  are 
neither  preceded  nor  followed  by  phases  of  a contrary  form,  and 
which  either  do  not  repeat  themselves,  or  do  so  only  at  very  long 
intervals  (ten  to  fifteen  years)  with  the  same  or  almost  identical 
characters. 

To  the  small  group  of  pure  forms  should  be  added  that  larger 
one  of  the  periodical  forms  of  the  same  nature.  Amongst  these  pure 
and  periodical  forms  are  the  relapses  at  intervals  of  from  five  to 
ten  or  more  years. 

The  relapse  and  the  length  of  the  interval  do  not  alter  the 
nature  of  the  disease,  but  they  reveal  the  nature  of  the  soil  in  which 
it  is  developed.  I do  not,  therefore,  see  any  reason  for  the  dis- 

673  43 


674 


PSYCHIATRY 


tinction  between  psycho-neuroses  (the  first)  and  degenerative 
psychoses  (the  second).  The  characteristics  of  the  pure  forms 
repeat  themselves  in  the  successive  attacks,  and  the  only  difference 
is  in  the  greater  depth  of  the  impression  which  the  first  attack 
leaves  on  the  mind.  When  the  disease  discloses  itself  in  persons 
imperfectly  developed,  symptoms  of  an  anomalous  character  creep 
into  the  picture  (childishness,  paranoidism,  selfishness,  impulsive- 
ness). In  no  case,  however,  should  these  be  confused  with  maniacal- 
depressive  insanity. 

The  fact  remains  that,  even  within  the  limits  of  normal  life, 
there  exist  opposite  temperaments,  which  preserve  the  same  features 
from  adolescence  to  maturity.  Some  present  an  appearance  of 
sadness,  have  a strong  tendency  to  view  the  dark  and  perilous 
side  of  things,  are  dull,  meditative,  quiet  or  timid,  even  when  they 
are  endowed  with  strong  intellect  and  a resisting  character  ; they 
are  not  fond  of  bustle  or  of  cheerful  company  ; some  are  even 
pessimistic.  However  little  these  characteristics  may  be  marked, 
we  recognise  in  them  a rudiment  of  melancholia. 

Others  present  an  opposite  character  : they  are  always  ready, 
rapid  m their  actions,  cheerful,  high-spirited,  often  superficial,' 
fond  of  stir  and  company,  carrying  wherever  they  go  gaiety  and 
good-humour.  The  embryo  of  mania  is  represented  in  this  char-  ’ 
.Lcter  . both  temperaments  are  lasting — they  are  constitutions.  ' 

It  is  certainly  true  that,  if  towards  the  decline  of  life  an  indi-  •' 
vidual  of  happy  disposition  becomes  insane,  the  insanity  will  ' 
very  probably  take  the  form  of  melancholia.  I have  seen  several  ’ 
instances  in  predisposed  persons,  but  the  explanation  is  to  be  \ 
found  in  the  fact  that  the  sadness  which  overtakes  the  mind  when 
maturity  is  passed  and  old  age  is  coming  on  is  usually  much  more  ' 
intense  in  these  gay  subjects,  stamiping  on  the  diseased  mind  the 
characters  of  restless  or  agitated  melancholia.  ■ 

Here  the  law  of  contrast  plays  its  part.  To  these  stable  char-  ! 
acters  there  correspond  pure  psychopathic  forms  which  cannot  be  \ 
confused  with  the  other  psvchoses.  .■ 

For  this  reason,  which  is  in  agreement,  if  not  with  the  statistics,  ’ 
at  least  with  the  ideas  of  Gucci  (Rivista  di  Patologia  nerv.  e 
mcnt.,  1899)  3-nd  with  those  of  Soukhanoff  and  Gannouchkine,  I 
hold  that  we  ought  to  preserve  in  the  nomenclature,  existing  as  • 
they  do  in  fact,  pure  mania  and  pure  melancholia,  and  that  with 
these  ought  to  be  aggregated  the  relapsing  and  periodical  forms, 
inaking  a gioup  quite  distinct  from  the  above-mentioned  maniacal- 
c epiessive  forms,  which  we  shall  describe  in  a separate  chapter. 

Pure  mama  is  relatively  rare.  A certain  number  of  manias  of 
the  old  authors  must  certainly  be  classed  with  other  psychoses 
better  known  to-da\%  and  especially  with  sensory  delirium,  pro- 
giessuc  paiahbis,  epilepsy,  and  hysteria.  The  existence  of  mania 


MANIA 


675 


has  been  wholly  denied  by  some,  but,  according  to  my  view,  wrong- 
fully. Taalmann,  for  example  (Allgemeine  Zeitschr.  /.  Psych., 
1897)  is  amongst  these,  struck  by  the  fact  that  out  of  105  cases 
admitted  as  mania,  the  diagnosis  could  only  be  upheld  in  four. 
In  my  opinion  greater  reliance  can  be  placed  upon  the  statistics 
of  Hinrichsen,  who  has  found,  relatively  to  the  cases  of  periodical 
and  circular  insanity,  a proportion  of  4-7  per  cent,  of  mania 
('  Statistischer  Beitrdge  zur  Frage  nach  der  Hdufigkeit  der  cinfachen 
aciiten  Manic,'’  etc.,  the  same  periodical,  1898).  I cannot  be  sure 
of  my  statistics  on  this  question  ; some  cases  of  periodical  form 
may  be  included  amongst  cases  of  genuine  mania.  I have  been 
able,  however,  to  follow  several  patients,  one  of  them  for  twent^^-two 
years  without  any  recurrence,  and  this  justifies  the  title  of  the  chapter. 

The  frequency  of  mania  must  certainly  be  influenced  on  the 
one  hand  by  the  character  of  the  race,  and  on  the  other  by  the 
more  or  less  exact  method  which  is  followed  in  the  examination 
of  the  patients.  Out  of  an  average  annual  admission  of  400 
patients,  I have  not  always  found,  during  the  lecture  courses, 
a typical  case  of  mania  to  present  to  the  students,  and  that,  too, 
in  face  of  a great  prevalence  of  sensory  insanities  and  melancholias. 
Seeing  that  mania  is  a little  more  frequent  in  the  Sicilian  than  in 
the  Neapolitan,  it  is  not  improbable  that  the  humble  character 
of  the  workman  and  of  the  whole  body  of  the  people,  tinged  with 
the  true  sadness  that  exists  even  in  the  middle  classes  through 
poverty,  disguised  though  it  may  be  by  the  bustle  and  gaiety 
attending  the  drama  of  life,  may  be  one  of  the  causes  of  the  rarity 
of  a disease  which,  until  a few  decennaries  ago,  was  held  to  be  very 
frequent.  It  figures  in  my  statistics  in  the  proportion  of  2 to  3 per 
cent,  of  the  admissions,  but  it  is  to  be  observed  that  this  figure 
is  obtained  from  the  nosographical  diagnosis  of  many  patients, 
and,  in  a great  centre  like  Naples,  is  due  to  the  want  of  an  assured 
control  of  the  facts  which  precede  the  confinement  or  succeed  the 
often  hurried  discharge  of  the  patients.  It  is  more  frequent  in 
women  than  in  men.  Out  of  1,367  males  admitted  to  the  asylum 
at  Naples  during  the  sexennial  period  1894-1900,  twenty-five  were 
affected  with  mania,  whilst  amongst  the  females  the  number  of 
cases  of  mania  was  also  twenty-five,  but  that  out  of  a figure  of  830 
admitted  during  the  same  sexennial  period. 

Compared  with  melancholia  this  proportion  is  very  low.  Out 
of  the  same  number  of  admissions  during  the  same  period  there 
were  109  ascertained  cases  of  melancholia  amongst  the  males, 
and  1 16  amongst  the  females.  Again,  if  we  subtract  from  the 
cases  of  mania  the  periodic  and  alcoholic  forms,  the  figure  is  much 
more  reduced.  This  fact  shows  how  erroneous  may  be  the  opinion 
pronounced  by  Leloyer  [Les  Spectres,  etc.,  1888),  who  declared 
mania  to  be  frequent  in  Italy,  especially  amongst  the  excitable 
populaces  of  the  provinces  of  .\bruzzi,  Calabria,  and  Apulia. 

43—2 


676 


PSYCHIATRY 


Pubert}7  and  adolescence  predispose  to  it,  but  it  is  observed 
in  all  ages,  although  it  is  more  rare  after  the  age  of  fifty-five.  Mental 
worry,  strong  emotions,  reverses  of  fortune,  fears,  scanty  nourish- 
ment, haemorrhages,  exposures  to  the  sun,  traumatic  affections  of 
the  brain,  and  a few  drugs,  such  as  salicylic  acid  (Robinson,  Reid) 
have  been  mentioned  as  causes  of  mania ; but,  apart  from  those 
cases  depending  on  intoxication  from  alcohol  and  salicylic  com- 
pounds, these  causes  act  by  preparing  the  soil  for  auto-intoxications. 

Mania  consists  essentially  in  an  emotional  disturbance  of  the 
personality,  the  tone  of  which  becomes  altered  in  the  direction  of 
pleasing,  cheerful  sensations.  There  is  a prevailing  consciousness 
of  the  pleasure  of  living,  and  exaltation  of  the  ego,  which  becomes 
exuberant,  strong,  assured,  often  haughty.  For  the  maniac  there 
no  longer  exist  any  difhculties  or  internal  or  external  resistances. 
He  abandons  all  the  polite  aids  (delicacy,  propriety,  opportunity, 
etc.)  which  make  instinctive  life  difficult,  and  which  adapt  it  to 
so  many  new  exigencies. 

The  maniac  is  a person  who  is  cheerful,  hilarious,  talkative, 
facetious,  sometimes  generous,  often  intolerant.  The  potentiality 
of  the  peculiar  attitudes  of  the  consciousness  increases  in  propor- 
tion to  the  exaltation  of  the  feeling  of  strength  and  health. 

The  reflective  power  is  diminished  and  reduced  to  a minimum, 
even  to  complete  disappearance,  and  the  afflicted  one  abandons 
himself  to  a thoughtless  life,  or  engages  in  arduous  or  dangerous 
undertakings  beyond  his  real  physical  and  economical  potentiality. 
The  diminished  resistances  leave  free  course  to  words  and  actions 
that  are  useless  and  often  incoherent.  As  he  has  nothing  in  the 
past  or  in  the  present  with  which  to  reproach  himself,  moral  senti- 
ments having  disappeared,  the  thought  of  something  that  will 
give  him  pleasure  finds  a ready  passage  to  the  field  of  action.  This 
does  not  depend  upon  a preponderance  of  the  reflex  motor  apparatus 
of  the  cortex,  to  the  exclusion  of  the  higher  centres,  as  held  by  some 
German  authorities,  who,  with  marvellous  confidence,  localize 
melancholia  and  mania  in  determined  cerebral  mechanisms.  Putting 
aside  the  imaginative  nature  of  these  authors,  concealed  behind 
promises  of  anatomical  and  physiological  positivism,  we  have  the 
fact  that  the  tension  and  the  high  motor  potential  in  the  motor 
centres  arise  from  the  fundamental  sentiment  of  the  exalted  ego, 
which  gives  pleasure,  and  from  the  increased  tension  in  the  whole 
cerebral  field  (images  and  ideas)  with  progressive  loss  of  the  selective 
power  over  the  ideas,  and  the  prevalence  of  the  simpler  or  older 
mental  organizations,  which  discharge  themselves  through  the 
shortest  circuits. 

In  the  turmoil  the  highest  products  of  thought  and  sentiment 
are  overthrown  by  the  sensory  throng,  which  normally  raises  the 
motor  potential.  The  time  of  reaction  and  of  discrimination  is 
diminished,  even  to  the  point  of  disappearance.  At  the  same 


MANIA 


677 


time,  the  tone  of  the  organic  life  is  much  strengthened.  The  circu- 
lation is  more  active,  respiration  more  ample,  the  appetite  stronger, 
digestion  often  more  rapid,  the  muscular  force  more  resistant, 
sexual  instinct  keener  and  less  easily  appeased. 

We  distinguish  three  forms  of  mania — the  mild  form,  or  hypo- 
mania,  the  typical,  and  the  grave. 

Mild  Mania. — In  this  form  change  of  sentiment  is  much  more 
pronounced  than  ideative  derangement.  Here,  more  than  in  the 
other  forms,  we  have  revealed  the  true  nature  of  the  disease,  as  a 
disturbance  of  the  sentiment  and  tone  of  the  mind.  There  pre- 
cedes often  a period  of  some  days,  and  even  of  some  weeks,  during 
which  the  subject  observes  a varying  number  of  derangements  : 
bad  digestion,  constipation,  want  of  appetite,  a dry  tongue,  heavi- 
ness in  the  head,  a feeling  of  heat,  headache,  mental  dulness,  bad 
humour,  affective  irritability,  a sense  of  weakness,  sometimes  fits 
of  hypochondria  of  short  duration,  and  sleep  interrupted  or  dis- 
turbed by  bad  dreams.  Then  one  day  or  other  all  is  changed, 
sometimes  almost  in  a moment,  and  most  frequently  on  awakening 
in  the  morning.  The  subject  is  conscious  of  a feeling  of  lightness 
and  well-being : the  kinsesthesis  is  much  heightened,  the  head  is 
clear,  ideas  flow  easily,  and  the  mind  is  serene  ; there  succeeds  a 
feeling  of  well-being,  internal  resistances  disappear  (the  annoyance, 
weariness,  sufferings,  muscular  weakness),  the  appetite  is  improved, 
and  a true  joy  invades  the  mind. 

The  patient’s  gaiety  much  exceeds  the  bounds  of  physiological 
happiness  ; he  feels  a great  desire  to  move  about ; he  is  strong, 
self-confident  ; his  life  is  free  and  unhampered  in  whatsoever  direc- 
tion his  activity  may  be  ; he  is  hilarious,  facetious,  loquacious, 
likes  the  company  of  friends,  and  searches  for  them  in  their  houses 
and  places  of  resort,  feels  the  need  of  doing  something  and  of 
diverting  himself,  drinks  more  than  customary,  and  the  sexual 
instinct  is  louder  in  its  demands  than  usual.  In  this  state  of  the 
feelings  and  of  the  mental  disposition,  arising  in  its  turn  from  the 
exalted  kinsesthetic  sentiment,  the  sensibility  to  pain  is  diminished, 
the  intellect,  moreover,  becomes  keener  and  more  active,  percep' 
tion  is  more  rapid,  and  the  memory  ready  and  faithful,  but  the 
associative  hyperexcitability  and  the  exuberance  of  ideas  lead  to 
judgments  sometimes  strange  and  paradoxical ; the  language  is 
more  abundant,  the  tone  of  the  voice  higher  ; the  patient,  if  edu- 
cated, solves  with  greater  ease  rebuses  and  charades  ; lucid  ideas 
come  with  greater  facility,  succeeding  and  pursuing  each  other, 
and  retaining  fair  logical  relations  with  one  another,  save  for  certain 
strange  relationships  which  the  maniac  sees  between  things  and 
appears  to  understand  between  ideas,  thus  endeavouring  to  conceal 
the  eccentric  and  even  paradoxical  nature  of  his  j udgment s . Amongst 
friends,  and  sometimes  also  amongst  strangers,  he  is  emphatic  ; 


678 


PSYCHIATRY 


he  writes  a great  deal  in  prose,  but  more  especially  in  verse  ; he 
is  witty,  ironical,  and  sarcastic,  sometimes  unseasonably  so,  with 
but  little  reserve,  and  sometimes  even  obscene.  The"  power  of 
attention  being  diminished,  the  psychic  processes  are  rendered 
facile,  hence  the  ready  resolution  of  all  the  motor  intuitions,  free 
from  the  restraints  of  the  inhibitory  powers,  now  weakened  and 
overcome  ; not  infrequently  he  becom.es  insolent,  and  acts  in  a 
perverse  manner  when  contradicted  in  the  home  and  outside. 
He  displays  quite  a great  activity,  is  never  at  rest,  does  not  sleep 
at  night,  makes  a number  of  resolutions,  followed  by  a single 
attempted  action.  In  this  these  sufferers  show  a notable  defect 
of  the  will,  as  proved  by  the  fact  that  after  recovery  they  declare 
that  they  were  unable  to  restrain  themselves  (case  of  Forel).  Some- 
times the  resolution  is  stronger,  when  the  idea  of  an  undertaking 
is  longer  nursed,  in  view  of  the  brilliant  success  promised  by  the 
individual’s  activity,  which  has  been  excessively  increased  in  pro- 
portion with  the  feeling  of  health  and  the  readiness  of  the  intellect. 
Through  a process  of  allegorizing  his  vigour,  the  maniac  no  longer 
sees  obstacles  to  the  carrying  out  of  his  projects. 

Misfortune  does  not  affect  him  ; he  can  borrow  money,  feeling 
certain  that  in  a short  time  he  will  make  a great  fortune  out  of  his 
undertakings.  A condition  of  psychic  arrest  is,  nevertheless,  not 
laie,  as  has  been  observed  also  by  others  (Kraepelin,  Weygand). 

In  some  it  is  a case  of  exaltation  of  the  ego,  without  or  with  a 
relatively  limited  rush  of  ideas,  accompanied,  however,  by  excessively 
facile  motor  reactions,  with  a hostile  and  aggressive  attitude,  for 
which  reason  the  sufferer  cannot  tolerate  opposition  to  his  asser- 
tions. Above  all,  over  close  relations  and  friends  he  assumes 
unwarranted  authority,  and  acts  with  violence. 

In  some  cases,  instead  of  exaltation  of  the  intellect  with  a rush 
of  ideas,  we  get  efflorescence  of  the  instinctive  life,  which  procures 
enjoyments,  unhampered  by  the  restraining  powers,  weakened  as 
they  are  by  disease. 

In  all  its  manifestations  the  exaltation  draws  its  character  from 
the  noimal  mental  disposition  of  the  particular  individual:  thus 
it  is  that  a doctor  speaks  of  being  a great  clinician,  discovering 
lemedies  for  incurable  diseases  ; a modest  surgeon  becomes  a sure 
and  successful  operator  ; a priest  becomes  a great  preacher,  his 
talent  being  unequalled,  his  conversation  brilliant ; the  commercial 
man  is  head  over  ears  in  business.  In  these  fiftul  assertions,  often 
made  under  the  pretence  of  jest,  we  perceive  the  germs  of  grandiose 
deliria  which  flourish  in  the  more  intense  form  of  mania. 

M ith  the  psychic  exaltation  the  somatic  phenomena  take  their 
jdac  e in  the  clinical  picture.  The  tactile  sensibility  is  exalted, 
the  muscular  force  is  somewhat  increased,  although  disordered, 
the  thiesliold  of  fatigue  is  farther  off,  the  circulation  is  more  active, 
the  pulse  of  higli  tension  and  increased  in  rate  (from  eighty  to 


MANIA 


679 


ninety  beats  in  the  minute),  the  face  more  lit  up,  the  eyes  sparkling, 
the  temperature  normal,  or  a few  degrees  higher,  the  appetite 
’usually  increased. 

Typical  Mania.  —In  this  form  the  exaltation  is  much  greater.  The 
disease  loses  the  characteristic  of  a profound  alteration  of  the  senti- 
ments and  mental  disposition  in  the  direction  of  a feeling  of  pleasure, 
joy,  hilarity,  contentment,  strength,  and  activity,  or  irritation,  and 
assumes  more  the  appearance  of  a grave  disturbance  of  the  intellect. 
Whilst  in  the  mild  form  the  reasoning  process  is  preserved,  allowing 
at  the  utmost  original,  or  paradoxical  but  true,  associations  to 
be  perceived,  in  the  typical  form  these  associations,  which  give  at 
least  the  appearance  of  reasoning  in  what  we  consider  sometimes 
as  originality,  eccentricity,  singularity,  are  broken  by  the  rapid 


Fig.  81. — Example  of  Typical  Mania. 


onrush  of  the  psychic  waves.  The  predominant  phenomenon  is 
a great  flow  of  ideas,  which  resolve  themselves  into  movements 
with  a rapidity  and  muscular  elasticity  sometimes  surprising. 
Every  sensory  impression  produces  an  effervescence  of  images  and 
thoughts,  which  in  turn  translate  themselves  into  words  and  acts  ; 
every  idea  has  behind  it  a number  of  others  with  the  relative  motor 
intuitions,  which  are  free  from  any  restraining  influence  whatsoever, 
or  any  process  of  selection.  All  crowd  on  the  motor  paths,  and  thus 
arise  the  great  unrest  and  the  extraordinary  and  incoherent  loquacity 
of  such  patients. 

As  can  be  readily  understood,  in  this  case  the  incoherence  depends 
upon  quite  a particular  mechanism  : given  the  exaltation  of  the 
psychic  activity,  any  external  or  internal  stimulus  puts  in  motion 
and  effervescence  a great  part  of  the  psychic  patrimony.  The 


68o 


PSYCHIATRY 


lower  and  the  higher  elements  mingling  together,  all  in  a turmoil, 
throng  the  threshold  of  consciousness,  which  in  turn  is  unable  to 
arrest  or  hinder  any  of  them,  and  the  way  being  clear,  free  vent 
is  given  to  all  the  intellectual  components  of  the  excited  and  troubled 
personality.  The  inhibitory  powers  are  rendered  unfit  to  perform 
their  functions.  The  tone  of  the  mind  is  hilarious  or  irritated, 
uniestrainedly  and  excessively  merry,  or  foolish  and  aggressive. 
The  individual  is  not  only  loquacious  and  incoherent  in  his  extra- 
oi  dinary  talkativeness,  passing  giddily  from  one  thing  to  another,  ■ 
according  to  the  variety  of  the  stimuli,  but  sings,  bawls,  skips,  ; 
runs,  stamps  about,  whistles,  insults,  threatens,  spits,  makes 
obscene  gestures,  exposes  the  genitals,  abandons  himself  to  lewd 
acts  and  erotic  invitations,  divests  himself  of  his  clothes,  and 
tears  and  destroys  them  if  he  meets  any  obstacle.  Whilst  in  mild 
mania  there  is  a tendency  to  write  verses  in  large,  unequal  and 
sometimes  disordered  handwriting,  in  the  typical  form  the  writing 
is  much  more  irregular,  the  sentences  are  half  written,  the  lines 
incomplete,  the  characters  large,  and  neologisms  and  symbols  are 
found  in  great  number.  The  maniac  does  not  bend  heiore  diffi- 
culties ; if  he  is  kept  at  bay,  especially  by  members  of  his  own  familjq 
he  breaks  out  into  violence,  becomes  hostile,  threatening  and  destruc- 
ti\e.  At  a moment’s  notice  the  personality  abandons  the  hilarious 
habit  and  gets  into  a passion,  asserting  the  ego  with  great  violence,  i 
'without  regard,  scruple,  or  remorse.  This  condition  of  things  i 
persists  for  several  weeks  or  some  months,  there  being  only  brief 
truces  , sleep  is  much  diminished,  and  during  the  night  there  is  ^ 
continued,  sometimes  with  greater  confusion,  the  dancing  and  ' 
singing  which  have  marked  the  day. 

Sensory  disturbances  almost  always  exist ; illusions  depending 
on  the  images  that  occupy  the  consciousness  at  any  given  moment  ; 
are  very  frequent  ; they  are  very  fleeting,  have  no  hold  on  the  { 
mind,  and  do  not  determine  any  secondary  judgment,  much  less  | 
any  change  in  the  humour.  \ 

With  regard  to  hallucinations,  although  nearly  all  authors  ^ 
speak  of  their  presence  in  this  form  of  mania,  I am  inclined  to  believe  ^ 
that  they  are  very  rare.  What  we  have  in  this  case  is  reall}*  a 
matter  of  very  vivid  and  coloured  images  depending  on  the  exalta- 
tion of  the  whole  psychic  sphere,  and  we  shall  at  the  very  utmost 
be  able  to  speak  of  psychic  hallucinations.  From  accurate  observa-  i 
tions  of  several  cases  of  pure  and  typical  mania,  I am  led  to  exclude 
the  piesence  of  true  hallucinations  from  this  psychosis,  and  to  hold 
that  their  supposed  prevalence  arises  from  an  erroneous  interpreta- 
tion of  the  manifestations  of  the  patient  ; or,  if  present,  they  are 
really  episodes  of  exaltation  of  other  psychoses,  or  of  the  maniacal 
loims  of  sensory  insanit}^  which  in  the  past  has  certainly  been 
confused  with  pure  mania. 

As  a lule,  expansive  deliria  flourish  from  the  very  outset.  The 


MANIA 


68i 


exaltation  of  the  ego  animates  them.  They  are  changeable,  fleeting, 
like  dazzling  lights,  ever  flitting  from  place  to  place.  Maniacs  are 
rich,  have  possessions,  are  great  commercialists,  are  very  capable, 
and  have  unsurpassable  talent.  These  deliria  are  often  mixed 
promiscuously  with  ideas  of  persecution,  with  religious  deliria, 
and  with  just  ideas  ; they  often  last  for  some  time  after  the  rush 
of  ideas  has  ceased.  Whilst  substantially  the  ego  is  hypertrophic 
and  reactive,  the  delirious  manifestations  are  only  an  unneces- 
sary coat  which  the  patient  often  recognises  as  not  belonging  to 
him. 

The  instinctive  life  is  also  profoundly  disturbed  : such  patients 
eat  inordinately,  do  without  a spoon,  prefer  taking  their  food  with 
their  fingers,  soil  themselves,  eat  greedily,  drink  by  lowering  their 
mouths  into  the  dish,  throw  on  the  ground  the  plate  with  part  of 
the  food,  are  extremely  greedy,  sometimes  disgusting.  They 
urinate  wherever  they  are,  even  in  presence  of  others  when  the 
disease  is  becoming  chronic,  and  defaecate  in  the  room,  never 
seeking  to  go  to  the  water-closet.  They  take  no  care  of  their 
persons,  are  negligent,  wear  filthy  clothes,  unbuttoned  and  torn ; 
their  hair  is  dishevelled  and  beard  untrimmed. 

They  are  obscene  in  speech,  but  no  longer  enterprising  in  love, 
as  in  the  mild  forms.  In  bed  they  are  restless,  assuming  the 
strangest  positions,  removing  mattresses,  coverlets,  sheets,  rolling 
themselves  up  in  the  bedclothes,  and  having  no  repose. 

The  physical  phenomena  are  also  more  evident  in  this  than 
in  the  preceding  form.  The  reflexes,  normal  in  the  mild  form 
(Agostini),  are  often  exalted  in  the  typical. 

When  the  excitement  is  strong  and  prolonged,  the  patients 
lose  weight,  even  although  well  nourished,  but  more  especially  if 
they  are  originally  badly  nourished  and  anaemic,  a condition  of 
affairs  by  no  means  rare.  The  acidity  of  the  gastric  juice  is  increased 
(Leubuscher  and  Ziehen).  The  pulse,  which  at  the  beginning  is 
strong,  of  good  tension,  and  rapid,  at  length,  if  the  attack  is  not 
short,  rises  frequently  beyond  loo  beats,  and  becomes  small  and 
compressible.  The  arterial  pressure  is  found,  by  means  of  the 
manometer,  to  be  increased  by  several  millimetres  at  the  beginning 
of  the  disease.  In  the  early  stages  the  face  is  usually  lit  up,  the 
eyes  are  bright,  the  palpebral  fissure  increased,  in  some  cases 
like  the  eye  in  the  disease  of  Flaiani.  The  pupils  are  equal, 
and  react  readily.  In  this  respect  my  personal  observations 
contradict  the  assertions  of  some  authors  (Schotze,  Ball,  Regis, 
Wagner,  Mendel,  Krafft-Ebing,  and  others),  who  noticed,  even 
in  the  interparoxysm al  periods,  inequality  of  the  pupils.  I have 
reason  to  believe  that  even  during  the  time  when  such  obser- 
vations were  made  true  mania  was  confused  either  with  sensory 
delirium  (maniacal  form),  or  with  the  maniacal  stage  of  progressive 
paralysis. 


682 


PSYCHIATRY 


Grave  Mania.— This  form  consists  of  an  aggravation  of  all  these 
symptoms,  with  an  exaltation  which  reaches  the  degree  of  destruc- 
tive fury  directed  against  both  persons  and  things.  It  may  be 
held  that  the  fury  described  by  some  old  authors  is  only  a very 
fleeting  phase  of  typical  mania,  or  one  of  the  forms  that  clinical 
and  psycho-pathological  investigation  has  differentiated  and  dis- 
tinguished to-day,  such  as  acute  sensory  delirium,  acute  delirium, 
the  epileptic  equivalent,  and  progressive  paralysis. 

The  duration  of  the  disease  varies  from  a few  weeks  to  two  oi 
more  years.  The  attacks  are  shorter  in  youth  than  in  advanced 
age.  Sometimes  in  adult  life  and  in  the  presenile  period  it  assumes 
the  chronic  form,  which  is  prolonged  for  years,  with  the  same  miti- 
gated characteristics,  and  in  most  instances  terminates  in  dementia. 

Diagnosis.— VwxQ  mania  must  be  diagnosed  from  the  history 
of  the  whole  disease,  which  begins  with  the  same  symptoms  as 
distinguish  it  throughout.  The  want  of  a true  melancholy  period 
at  the  commencement  of  the  disease,  except  for  the  prodromal 
period  of  malaise,  such  as  occurs  in  almost  all  acute  diseases,  and 
which  must  not  be  confused  with  a melancholy  phase,  the' pre- 
vailingly cheerful  tone  of  mind,  and  the  extraordinary  facility 
with  which  all  the  psychic  processes  are  manifested  with  intellectual 
vivacity  and  abundance  of  ideative  products,  however  deranged, 
the  slight  influence  possessed  by  the  various  sensory  disorders' 
owing  to  their  slight  intensity  and  feeble  determinative  power  as 
compared  with  those  observed  in  so  many  other  psychopathies, 
aie  all  suffleient  data  to  distinguish  true  mania  from  the  exaltation 
which  is  met  with  in  many  other  mental  affections.  The  absence  of 
true  phenomena  of  dementia,  the  subtle  spirit  which  maniacs 
show,  their  ironical  sayings,  their  ready  memory  for  poetry  and 
prose  formerly  forgotten,  and  the  absence  of  somatic  phenomena 
such  as  tremors,  inequality  of  the  pupils,  initial  disorders  of  speech- 
ai ticulation,  abolition  of  the  patellar  reflex,  etc.,  permit  in  the 
gieatei  number  of  cases  the  differentiation  of  mania  from  the 
exalted  form  of  progressive  paralysis. 

From  the  maniacal  manifestations  of  epilepsy  distinction  is 
made  by  the  history  of  the  case,  the  anthropological  signs,  the 
great  impulsiveness,  and  the  irritability.  The  functional  marks 
of  hysteria — the  greater  mobility  of  humour,  the  prevailing  mystic 
and  erotic  disposition,  and  the  previous  history — will  facilitate 
tile  diagnosis  of  maniacal-hysterical  insanitv. 

The  pathological  anatomy  of  mania  is  not  known.  The  con- 
gested states  met  with  by  the  old  authors  are  not  characteristic 
of  mama,  and  cannot  be  attributed  to  it,  since  in  the  past  mania 
has  been  confused  with  other  states  of  exaltation  well  defined 


MANIA 


683 


to-day.  Alania  may  even  be  accompanied  by  amemia  of  the  nerve- 
centres  (Mirto).  The  manias  which  complicate  grave  infective 
diseases  are  of  rather  too  complex  an  origin  to  allow  of  a definite 
post-mortem  finding,  hiven  the  more  accuiate  lessarches,  like 
those  of  Orr  (‘  A Contribution  to  the  Pathology  of  Acute  Insanity,’ 
Brain,  1902),  who  found  in  some  acute  forms  of  insanity  marked 
chromatolysis  and  eccentric  displacement  of  the  nucleus,  have  not 
advanced  our  knowledge  of  the  subject  under  consideration,  because 
these  same  alterations  are  found  also  in  other  psychoses ; and, 
on  the  other  hand,  these  acute  forms  of  insanity  cannot  be  held 
to  be  typical  or  grave  forms  of  mania. 

The  nuclear  proliferation  found  by  Repping,  the  fatty  and  pig- 
mentary degeneration  of  the  nerve-cells,  the  chromatolysis  with 
increase  of  neuroglia  found  by  Anglade,  the  granular  myelinic 
alterations  found  by  Mirto,  and  some  other  analogous  findings,  do 
not,  in  the  present  state  of  our  knowledge,  warrant  us  in  defining 
the  pathological  anatomy  of  mania.  The  autopsy  of  one  typical 
maniac  who  remained  excited  and  lucid  for  more  than  two  years, 
then  died  of  pneumonia,  revealed  a splendid  hyperjumic  veining 
of  the  dura  mater,  which  was  rose-coloured,  and  of  the  pia  mater. 

Prognosis. — The  prognosis  is  in  most  cases  favourable.  Only 
the  grave  forms  unduly  prolonged  in  weak,  anaemic  persons  are 
dangerous.  Eighty  to  ninety  per  cent,  of  cases  recovei.  The 
prognosis,  however,  ought  always  to  be  guarded  in  view  of  the 
future,  since  there  remains  a tendency  towards  the  repetition  of 
identical  attacks,  especially  in  the  young,  or  a tendency  towards 
establishing  some  periodical  and  circular  forms  which  leave  little  or 
no  hope  of  cure.  The  fact  is  that  in  a case  of  mania  the  clinician 
has  no  means,  if  it  is  the  first  attack,  of  distinguishing  the  pure 
from  the  periodical  or  circular  form.  The  cure  may  be  instantaneous, 
and  happen  in  consequence  of  intercurrent  diseases,  after  blood- 
letting (Raggi  and  Bergonzoli),  pleurisy  (Willerdich),  or  pharyngitis 
(Schultze). 

Therapy. — From  the  very  beginning  of  the  disease  the  maniac 
must  always  be  isolated.  In  contrast  to  the  melancholiac,  who 
can  be  kept  at  home,  surrounded  by  domestic  affections,  the  maniac 
must  be  removed  from  the  stimuli  of  variable  surroundings  which 
in  different  ways  increase  the  potential  of  excitement  in  his  brain. 
Restlessness  and  enterprise  associated  with  great  deficiency  of  the 
restraining  and  critical  powers,  expose  the  maniac  to  certain  ruin, 
and  the  facility  with  which  he  reacts  on  his  surroundings  in  an 
impetuous  manner,  without  measure,  and  without  a just  apprecia- 
tion of  the  acts  he  performs,  are  manifestations  of  the  necessity 
for  confinement.  We  may  except  very  mild  forms  where  the 
disease  makes  the  person  affected  agreeable — of  course,  only  up  to 


684 


PSYCHIATRY 


a certain  point — but  in  all  other  cases  the  maniac  is  not  a patien 
to  be  treated  in  his  own  home.  Wherever  he  is  kept,  one  indisi 
pensable  condition  is  that  he  be  removed  from  the  greatest  possibl 
number  of  stimuli.  As  to  the  means  of  restraint,  experieno 
teaches  that  the  more  free  and  in  the  open  the  patients  are  left 
the  less  are  they  excited.  1 

In  the  first  days  of  the  attack  there  is  nothing  so  efficacious  a:| 
etiological  treatment : to  purge  the  intestines,  disinfect  them  witl 
copious  washings,  and  to  practise  abundant  hypodermic  transfusion:! 
on  alternate  days  (in  the  typical  and  grave  forms),  is  the  rule  foLi 
lowed  in  my  wards.  The  application  of  leeches  may  be  useful  ir 
the  graver  cases  and  where  a congested  state  of  the  head  appean 
very  evident.  Tepid  baths  have  been  much  recommended,  thi 
baths^  being  prolonged  from  one  to  eight  hours  at  the  temperature 
of  34°  fo  35°  C.,  with  or  without  cold  douches  or  cold  compresses 
on  the  forehead. 

The  food  during  the  first  days  ought  to  consist  of  substances 
which  give  the  smallest  quantity  of  ptomaine.  I am  in  the  habit 
of  excluding  flesh  meat  from  the  dietary  of  these  patients.  Milk 
and  farinaceous  foods  are  the  most  suitable.  After  the  first  weeks 
are  passed  it  is  no  longer  beneficial  to  keep  the  patients  on  this 
diet,  since  the  morbid  manifestations  depend  on  changes  that  have 
already  taken  place  in  the  cortical  elements  of  the  brain. 

In  these  cases  the  symptomatic  treatment  gives  poor  results.; 
A very  large  number  of  sedatives  and  hypnotics  have  been  recom- 
mended, with  but  temporary  success  ; among  these  are  chloral,^ 
paraldehyde,  bromide,  sulphonal,  morphine,  hyoscine,  duboisine,  etc.' 

Except  bromide,  which  can  be  given  freely  without  injur}^  or 
danger  (4  to  5 grammes  per  day,  with  4 to  5 drops  of  tincture  of 
hyoscyamus  freshly  prepared),  and  sulphonal,  all  these  drugs  are, 
more  or  less  insidious — hyoscine  and  duboisine  more  so  than  any: 
of  the  others,  so  that,  after  a period  of  trial,  I have  given  overj 
the  use  of  these  latter  in  my  practice.  With  the  others  it  is  neces-' 
sary  to  be  sparing.  It  appeared  to  me  that  the  prolonged  use  of^ 
any  of  these  hypnotics  did  not  facilitate  the  cure,  and,  above  all,^ 
did  not  shorten  the  course  of  the  disease. 


CHAPTER  XIV 


PURE  MELANCHOLIA 

This  is  essentially  represented  by  a change  in  the  affective  tone  of 
the  personality  in  the  direction  of  a painful  feeling,  accompanied  by 
a slowness  of  all  the  psychic  processes,  amounting  even  to  psychic 
arrest  and  to  static  concentration  of  thought  on  distressing  sub- 
jects, with  a tendency  to  disjunction  of  the  personality,  which 
depreciates  itself  to  the  humblest  form,  and  even  to  dehnite  sup- 
pression of  the  ego. 

Some  hold  that  it  is  the  concentration  of  thought  on  painful 
subjects  that  puts  and  polarizes  the  mind  in  a painful  state.  Experi- 
ence demonstrates  the  great  prevalence  of  the  sad  humour,  reaching 
even  to  anguish,  and  this  necessarily  is  associated  with  the  dis- 
tressing and  monotonous  content  of  the  intellect.  Whichever  be 
the  mode  of  commencement  of  the  disease,  it  is  certain  that  these 
two  facts  coexist  and  represent,  together  with  the  inhibition,  the 
integral  elements  of  the  disease,  which  in  the  somatic  held  is 
represented  by  all  those  functional  modihcations  accompanying 
the  emotions  of  grief  and  fear  (vide  Part  II.). 

According  to  Kraepelin,  the  melancholia  which  develops  before 
the  age  of  thirty  is  never  a simple  form ; as  a rule  it  ends  either  in 
dementia  prsecox  or  in  circular  insanity.  This  issue  takes  place 
whatever  be  the  form  of  melancholia,  and  even  when  the  perceptive 
process  is  preserved. 

In  my  opinion  simple  forms  of  melancholia  certainly  do  exist, 
even  amongst  young  people  ; such,  however,  are  much  more  rarely 
met  with,  and  may  terminate  either  in  recovery  or  in  dementia.  The 
latter  issue  does  not  change  the  character  of  the  disease  as  a simple 
psychosis.  Relapses  occur  in  identical  forms,  sometimes  owing  to 
changed  organic  conditions,  such  as  the  puerperium  ; but  even  in 
this  case  we  cannot  speak  of  relapsing  melancholias  analogous  to 
the  periodical,  as  Jolly  formerly  observed. 

This  observation  of  mine,  made  quite  a number  of  years  ago, 
agrees  in  almost  all  respects  with  those  of  Sachs  (Statistischen 
Beitrag  zur  Kenntniss  der  einfachen  u.  periodischen  Melancholie, 
1899),  who  found  an  almost  equal  number  of  persons  suffering  from 

685 


686 


PSYCHIATRY 


pure  melancholica  in  the  third,  fourth,  and  fifth  decennaries,  in  con- 
tradiction to  that  doctrine  which  teaches  that  melancholia  is  a 
disease  of  involution. 

If  melancholia  is  to  be  regarded  as  a disease  of  incipient  senility, 
as  is  maintained  by  Kraepelin  and  many  of  his  followers,  this  can 
be  admitted  in  a psychological  sense  only,  and  not  in  the  strict 
meaning  of  the  word.  In  fact,  Arnaud  (Rivista  di  patologia  nervosa\ 
e mentale),  in  an  analysis  of  162  cases  of  melancholia  (100  females! 
and  62  males),  found  the  disease  in  all  ages  ; the  greatest  number! 
occurred  in  middle  age. 

Certainly,  in  the  majority  of  melancholiacs  we  find  a lowering! 
of  that  vital  tone  characteristic  of  youth  and  maturity,  and  a notable 
deterioration  of  the  whole  organic  function,  sometimes  connected 
with  true  organic  lesions  and  with  all  the  signs  of  a premature  senile 
involution  ; but  the  indisputable  existence  of  pure  lypemania  in  the 
third  decennary  of  life,  which  either  ends  in  recovery  or  relapses 
after  many  years,  contradicts  the  generalization  of  this  conception. 

We  distinguish  different  forms  of  melancholia. 

Simple  Melancholia.- — This  first  form  is  not  very  rare.  In  it 
neither  hallucinations,  illusions,  nor  deliria  are  met  with  ; often, 
indeed,  the  individuals  affected  are  more  than  usually  lucid. 

This  melancholia  without  delirium  is  represented  by  a state  of’ 
low  spirits  and  dejection,  and  by  intense,  continuous  moral  suffering, , 
with  profound  and  invincible  discouragement.  There  is  perfect, 
mental  integrity,  save  for  the  concentration  of  the  intellect  on' 
sorrowful  subjects,  whilst  the  personality  is  attacked  by  a keen  ‘ 
and  killing  frost,  which  freezes  up  every  internal  of  external  source ! 
of  joy.  A letter  written  to  me  by  a young  man  who  consulted 
me  affords  an  example.  I gave  him  words  of  encouragement,  : 
and  for  some  days  he  showed  himself  somewhat  comforted,  and , 
hoped  for  cure.  Here  is  the  letter  : j 

i 

‘ Signor  Professor,  \ 

' I have  until  to-day  followed  out  with  the  greatest  diligence ! 
the  treatment  you  prescribed  for  me,  and  I hoped  to  obtain  from  it  a l| 
little  improvement.  Alas,  what  a rude  awakening  ! I am  still  as 
unhappy  as  ever,  with  this  difference,  that  whilst  formerly  I nourished 
a little  hope,  now  I despair  of  ever  becoming  well.  A formidable  barrier 
has  been  erected  before  my  mind,  and  it  obtrudes  itself  so  inexorably 
on  me  as  to  drive  awa}^  from  my  mind,  if  I can  say  I possess  one,  the  ' 
very  shadow  of  hope. 

In  this  indefinable  state  the  idea  of  suicide  presents  itself  spon- 
taneously and  opportunely  to  my  mind,  but  before  I embrace  it  I wish 
for  the  last  time,  through  you,  to  entreat  science  to  use  the  means,  if 
any  there  he,  to  combat  my  fatal  disease. 

I foresee  too  well  the  answer,  but  I wish  to  indulge  a little  longer  ; 
in  unfounded  ho])es.  Do  let  my  painful  position  impress  itself  upon  ■ 
you,  and  consider  a little  what  unhappiness  and  grief  I suffer  in  feeling  i 
myself  apathetic,  unconscious  of  myself,  morally  insensible — a mere  , 
automaton,  yet  fully  aware  of  my  moral  nullity. 


PURE  MELANCHOLIA 


687 


‘ With  the  most  passionate  and  intense  prayer  for  help  and  relief 
that  has  ever  gone  out  from  a human  heart  I turn  to  you,  most  esteemed 
professor.  I hope  you  will  not  remain  insensible  to  misery  so  great  as 
mine,  but  be  willing  to  interest  yourself  kindly  in  a young  man  who, 
still  in  the  bloom  of  youth,  finds  himself  forcibly  drawn  into  the  most 
cruel  dilemma — on  the  one  hand,  a wretched  existence  ; on  the  other, 
death.  Truly,  for  me,  death  and  my  present  life  mean  the  same  thing, 
since  I am  now  morally  nothing  but  a brute,  or  little  better  than  an 
animal  obedient  to  instinct.’ 

In  this  letter  we  have  all  that  is  necessary  for  forming  the 
clinical  picture  of  simple  melancholia. 

The  formidable  barrier  to  which  the  young  man  refers  is  only 
the  psychic  coaction  which  prevents  the  ideas  and  the  acquisitions 
constituting  the  mental  patrimony  from  passing  into  the  field  of 
consciousness,  which  instead  is  flooded  by  an  immiense  and  inde- 
finable anguish  and  by  groups  of  ideas  relating  to  profound  sadness. 

There  is  always  present  in  melancholiacs  a feeling  of  darkness 
and  despaii  of  ever  again  finding  joy  in  life,  and  hence  arises  the 
tendency  to  the  suppression  of  the  proper  being. 

From  the  moment  courage  fails  them  and  they  no  longer  feel 
affection,  when  hopes  have  ceased  to  urge  them  and  ideas  to  nourish 
the  consciousness,  when  neither  desires  nor  wishes  move  them  and 
interests  no  further  sway  them,  and  when,  instead,  grief  reigns 
supreme,  invading  and  conquering  the  whole  being  and  begetting 
weariness  of  life,  then  the  personality  is  potentially  suppressed. 

The  wretchedness  of  the  ego  and  the  nullity  to  which  it  recog- 
nises itself  reduced,  suggest  the  quality  of  brute  or  animal,  which 
the  melancholiac  attributes  to  himself  because  he  no  longer  feels 
any  of  those  virtues  from  which  flows  the  joy  of  existence,  and  the 
absence  of  which  gives  the  conception  of  unworthiness  that  charac- 
terizes this  morbid  state. 

In  general,  melancholiacs,  even  before  falling  ill,  are  morally 
hyperaesthetic.  This  condition  becomes  accentuated  in  the  form 
of  melancholia,  but  at  the  same  time  the  victims  become  self-centred. 
Their  own  intense  suffering  makes  them  insensible  to  that  of  others  ; 
they  speak  only  of  their  own  afflictions,  and  like  to  publish  them 
to  the  world. 

Another  characteristic  of  the  disease  is  despair.  As  long  as 
there  remains  a ray  of  hope,  the  disease  is  not  so  grave  ; confirmed 
melancholiacs  do  not  hope — all  is  finished,  all  is  lost  for  them. 

Moral  insensibility,  of  which  the  young  man  speaks  in  his  letter, 
is  another  phenomenon  frequently  observed.  There  are  some' 
who  grieve  because  they  have  no  affection  for  anyone,  and  because 
they  are  entirely  without  feeling  : the  mother  is  distressed  that  she 
has  no  longer  love  for  her  own  children  ; the  father  frets  because 
he  no  longer  feels  interest  in  the  management  of  his  business,  etc. 

When  there  is  consciousness  of  paralysis  of  the  affective  and 
intellectual  capacities,  the  personality  sees  itself  reflected  in  the 


688 


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world,  wretched,  reduced,  and  ruined,  and  that  which  is  the  effect 
becomes  a cause,  and  so  increases  the  grief. 

When  it  happens  that  grief  has  invaded  the  whole  soul  no  other 
escape  presents  itself  than  suicide,  which  is  inevitable,  being  the 
last  reflection  of  a psychic  personality  that  is  dying,  dragging  with 
it  into  nothingness  the  body  now  no  longer  in  harmony  with  it. 

The  melancholiacs  of  this  category  are  usually  gloomy,  solitary, 
torpid  ; they  no  longer  frequent  places  of  amusement  "where  life 
manifests  itself  in  the  pursuit  of  pleasure,  where  there  is  found  the 
relaxation  that  follows  work,  where  the  story  of  the  day  is  rewoven, 
and  a new  page  written  in  the  memory  of  each  one  ; neither  do  they 
go  to  the  theatre,  where  a number  of  sensory  and  aesthetic  pleasures 
soothe  the  soul  and  fit  it  for  the  struggle  of  the  morrow.  For 
melancholiacs  Nature  holds  no  further  joys.  Art  is  mute  ; all  things 
are  in  contrast  to  their  grief ; everything  increases  it,  nothing 
alleviates  it.  Caresses,  comforts,  encouragements,  either  have  no 
beneficial  effect  or  at  most  a very  fleeting  one,  and  may  even  have 
the  opposite  effect  of  increasing  their  sufferings  (psychalgia).  They 
suffer  from  precordial  pain  and  fits  of  profound  discouragement 
They  feel  as  if  a knot  were  in  their  brain,  torturing  and  frightening 
them.  The  fixity  of  ideas  gives  rise  to  true  obsessions,  and  makes 
them  despair.  In  this  state  they  lose  all  touch  with  the  social 
world,  and  abandon  every  enterprise  : they  have  no  hope  of 
success,  no  courage  to  confront  difficulties  ; nothing  interests  them 
any  longer ; they  become  fretful  and  tired  of  ever3dhing  ; and  as 
time  goes  on  the  anguish  increases,  like  an  ever-increasing  tension, 
till  it  reaches  the  limit  of  the  mind’s  capacity,  when  it  discharges 
itself  violently  in  destructive  action  against  persons  and  things, 
or  even  against  themselves  (raptus). 

At  other  times  they  are  in  a constant  state  of  unrest.  They  go 
about  seeking  comfort  from  doctors,  from  maiw  doctors,  from 
friends  and  relations  : they  cannot  do  otherwise,  for  they  become 
disheartened  when  alone  ; they  speak  of  nothing  but  their  malady, 
and  are  monotonous,  always  returning  to  the  same  theme — their 
grief,  their  unbearable  suffering,  their  desperation,  their  unhappi- 
ness ; no  one  sufficiently  understands  them  ; no  one  can  compre- 
hend how  much  the^^  suffer.  Often  they  do  not  sleep  ; they  lose 
all  appetite,  no  longer  enjoy  their  food,  decrease  in  weight. 

Closely  related  to  the  moral  grief,  and  sometimes  occurring  as 
a primary  fact,  there  is  almost  always  fear.  Grief  and  fear  are 
two  aspects  of  the  same  emotion  ; fear  of  something  is  the  appre- 
hension of  injury  therefrom,  and  hence  a grief.  There  are 
individuals,  however,  who,  apart  from  what  they  know  from  per- 
sonal experience  or  have  learned  from  others,  have  fear  of  the 
unknown.  In  this  case  we  have  an  indefinite  fear  which  does  not 
reduce  itself  to  the  concrete.  That  which  is  beyond  the  limits 
of  our  knowledge  weighs  like  an  imminent  danger,  just  as  the 


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689 


night-time  impresses  deeply  on  the  timid  soul  the  silence  of  Nature. 
Melancholiacs  with  a timorous  disposition  are,  as  a rule,  pano- 
phobists. 

Melancholia  with  delirium  is  the  most  frequent  of  all  the  other 
mental  affections  of  antiquity.  We  find  a very  considerable 
diversity  with  regard  to  the  psychic  content. 

In  Saul  the  melancholic  content  of  thought  was  the  curse  of 
God,  because  of  his  faults  ; in  Nebuchadnezzar,  King  of  Assyria, 
the  degradation  of  the  proper  personality  translated  itself  into 
giving  effect  to  the  belief  that  he  was  transformed  into  a beast. 

In  the  Middle  Ages  there  were  real  epidemics  of  melancholia 
with  demoniacal  content.  Thousands  of  individuals  believed  them- 
selves possessed  by  the  devil  and  transformed  into  beasts  (lycan- 
thropy). 

There  were  patients  of  this  form  of  melancholy,  to  whom  were 
given  the  name  of  lupomaniacs,  who  infested  the  country  districts 
to  such  an  extent  as  to  cause  special  laws  to  be  promulgated,  like 
that  by  the  English  Parliament  in  1573,  which  gave  permission  to 
the  country  people  to  hunt  the  lupomaniacs  who  roved  about  the 
districts.  Legal  proceedings  were  instituted  against  those  pos- 
sessed of  devils  and  against  the  supposed  sorcerers,  and  laws  were 
made  by  the  Parliaments  of  Rouen  (1643)  and  Provence  (1611),  etc., 
legalizing  the  tortures  of  the  stake. 

To-day  melancholia  has  assumed  another  character  : lycanthropy 
has  become  rare,  and  every  year  melancholia  with  demoniacal 
delirious  content  is  becoming  less  common. 

Melancholia,  like  many  other  mental  diseases,  reproduces 
in  the  tints  of  the  disease  the  character  of  the  individual  and  of  the 
times. 

In  simple  melancholia  grief  is  more  intensely  felt  than  in 
melancholia  with  delirium.  Interpretation  is  like  the  appease- 
ment of  the  grief,  which  is  aggravated  when  it  does  not  rest  on 
any  subjective  reason. 

Delirium  is,  as  it  were,  an  outcome  of  the  original  sorrowful  tension. 
It  has  been  very  often  affirmed,  especially  by  the  German  alienists, 
that  it  is  developed  through  an  allegorical  interpretation  of  grief, 
as  by  a process  of  reasoning,  through  that  tendency  of  the  spirit 
to  seek  the  reason  of  things  and  of  phenomena.  Investigations 
into  the  nature  of  the  patients,  their  ancestors  and  their  tendencies, 
have  furnished  me  with  positive  results  as  to  the  true  genesis  of 
such  deliria. 

Leaving  out  of  account  those  of  hallucinatory  origin,  I have 
found  that,  whilst  some  deliria,  such  as  those  of  witchcraft  and 
sorcery,  arise  by  a logical  process  from  interpretation,  the  greater 
number  of  them  arise  through  psychic  contrast  {vide  Part  II.). 
They  are  always  preformed  ideas  associated  with  the  emotion  of 

44 


690 


PSYCHIATRY 


fear  of  any  danger  whatsoever,  in  contrast  with  normal  ideas 
which  prevent  those  mental  productions  from  becoming  active. 
The  disintegration  of  the  personality,  an  effect  of  the  pathological 
emotions,  suppresses  the  normal  ideas  of  contrast,  or  deprives  them 
of  the  power  of  resisting  the  invasion  of  the  antagonistic  ideas. 

The  preformed  ideas  vary  in  nature  according  to  the  individual 
and  social  circumstances  of  each  person. 

Many  of  these  false  conceptions  lead  to  conclusions  of  personal 
unworthiness.  ^The  melancholiac  judges  himself  unworthy ; his 
personality  is  debased  and  humiliated,  and  so  he  accuses  himself 
of  sins  and  crimes  which  he  never  committed. 

^ Exaggerating  the  trifling  and  insignificant  facts  of  his  previous 
life,  he  affirms  that  he  has  committed  the  most  unlawful  actions, 
has  broken  laws  human  and  Divine,  has  committed  sins  unpardon- 
able in  the  sight  of  God,  is  irreparably  lost  and  damned.  He  pictures 
to  himself  hell,  fire,  devils,  and  the  terrible  punishments  that 
await  him.  These  are  the  so-called  deliria  of  auto-culpability, 
auto-accusation,  demonomania,  damnation,  and  perdition.  The 
last  two  deliria  represent  judgments  of  social  vengeance  : for  the 
faults  committed  he  will  be  arrested,  tortured,  executed  ; not  only 
he,  but  also  all  the  members  of  his  family,  will  have  to  undergo 
the  most  atrocious  punishments.  From  time  to  time  he  is  seized 
with  real  fits  of  grief  and  anxiety,  thinking  that  the  officers  of 
justice  are  at  hand  to  arrest  him  and  carry  him  off,  with  his  family, 
to  horrible  prisons,  and  he  regards  everything  as  lost. 

Another  form  of  melancholic  delirium  is  that  of  negation  in  the 
widest  sense  of  the  word.  The  dissolution  of  the  personality 
reflects  not  only  the  ego,  but  also  that  part  of  the  personality  which 
is  included  in  the  meum,  in  so  far  as  it  is  an  integral  part  of  it.  In 
this  case  the  melancholiac  affirms  that  he  no  longer  possesses  any- 
thing, that  he  has  ruined  himself  and  his  children  ; he  does  not 
know  what  to  do  ; he  has  no  longer  the  wherewithal  to  sustain  life ; 
his  children  will  have  to  beg  their  bread,  and  undergo  the  gi'eatest 
humiliations  and  the  most  atrocious  punishments. 

Some  others  affirm  they  have  lost  not  only  their  fortune  but 
also  their  family  ; they  have  no  longer  wife,  children,  or  friends  ; 
they  are  alone  in  the  world.  Proof  of  the  contrary,  in  fact,  does 
not  remove  this  false  conviction  from  their  minds. 

There  may  also  be  a delirium  of  persecution.  In  this  case  it 
differs  from  that  which  takes  place  in  the  paranoic  subject,  intense 
fear,  anxiety,  and  psychic  arrest  predominating.  Frequently  it  is 
the  delirium  of  poisoning,  of  poisonous  substances  being  in  the  food 
and  drink.  The  conviction  of  being  a victim  of  witchcraft  or  sorcery 
constitutes  a delirium  from  interpretation,  very  similar  to  the 
delirium  of  persecution. 

d he  hypochondriacal  delirium  is  not  rare  ; it  is  often  maintained 
b}’  intestinal  disturbances,  dilatation  of  the  stomach,  eczematous 


PURE  MELANCHOLIA  691 

eruptions,  and  in  alcoholists  by  paraestliesias  and  pains  in  different 
nervous  regions. 

In  these  cases  the  patients  afhrm  that  they  suffer  from  serious 
heart  disease,  that  the  blood  does  not  circulate,  the  bowels  do  not 
move,  that  the  brain  is  broken  up,  and  that  worms  swarm  in  the 
cranium.  This  delirium  sometimes  grows  worse,  assuming  the 
characters  of  the  delirium  of  negation  (see  Part  II.).  The  patients 
thus  affected  suffer  great  agitation  and  violent  terrors. 

^ All  these  deliria  indicate  a reduction  of  the  ego  and  the  imminent 
danger  which  threatens  it. 

In  other  cases  the  ego  is  transformed  (metabolism),  and  here 
we  have  several  factors  at  work.  Through  psychic  arrest,  which 
prevents  the  representation  of  the  various  images  and  also  of  a 


Fig.  82. — Representation  of  a Woman  Suffering  from  Melancholia,  with 
Delirium  of  Negation  and  Anguish. 

: small  part  of  the  intellectual  patrimony,  and  through  the  absence 
of  the  various  sentiments,  so  frequent  in  victims  of  melancholia, 
it  is  no  rare  thing  for  some  of  them  to  arrive  at  the  false  concep- 
tion of  being  no  longer  the  same  persons.  These  are  the  more 
grave  cases  of  lypemania.  The  disease  begins  with  the  patient’s 
feeling  out  of  sorts  ; he  suffers  from  insomnia  and  a distressing 
inability  to  direct  his  energies  ; a phase  of  anxiety  and  agitation 
follows.  The  sufferer,  with  a frightened  face,  only  gives  vent  to 
sighs  and  exclamations,— ‘ What  am  I to  do  ?’  ‘O  God,  I am 
dost !’ — and  incessantly  paces  the  room  with  his  hands  clasped  or 
Thrust  into  his  hair.  After  some  weeks  of  this  anxious  and  agitated 
I form  of  lypemania  (melancholia),  during  which  time  hallucinations 
I are  common  and  delirium  of  negation  becomes  pronounced,  the 
1 patient  loses  the  thread  of  the  history  of  his  proper  personality  : 
i 44—2 


692 


PSYCHIATRY 


he  no  longer  possesses  anything  ; his  estates  and  money  exist  no 
more  ; the  house  he  lives  in  is  no  longer  his  own  ; the  members  of 
the  family  who  assist  him  are  no  longer  his  relatives  ; nothing  in 
the  house — neither  furniture  nor  clothes — belongs  to  him  any 
longer  ; he  no  longer  possesses  anything  ! Thus  one  by  one  the 
components  of  the  psychic  personality  are  suppressed : on  the 
one  hand,  the  ideas  and  sentiments ; on  the  other,  all  the  components 
of  the  ego  included  in  the  meum  ; and,  with  this  profound  alteration 
of  the  kinaesthetic  feeling,  the  personality  no  longer  recognises 
itself  historically,  and  is  no  longer  capable  of  appreciating  its 
relations  to  time.  The  consequence  of  this  state  is  the  negation 
of  the  ego.  ‘ I am  not  X,’  said  one  lady  to  me  ; ‘ she  exists  no 
longer.  A great  catastrophe  has  occurred  and  led  to  her  disappear- 
ance. You  wish  to  call  me  X,  but  she  whom  you  call  X knows 
not  whence  she  comes,  when  she  was  born,  nor  how  she  comes  to 
be  here.  I see  A,  B,  C ’ (her  sisters,  whom  she  mentioned  by  name), 

‘ and  I know  that  you  are  Professor  Bianchi ; but  ^Irs.  X,  whom 
you  believe  you  are  visiting,  no  longer  exists.’  Her  recollections 
extended  up  to  the  ‘ great  catastrophe,’  which,  as  a cataclysm, 
had  overthrown  everything,  and  in  which  she  had  been  shipwrecked ; 
she  had  a confused  memory,  like  a dream,  of  the  original  X,  and 
could  not  account  for  her  present  existence  ; she  was  of  mysterious 
origin,  and  alone  in  the  world.  The  perception  of  things  and  of 
persons  existed,  and  also  the  process  of  recognition  ; but  the  funda- 
mental ground  of  this  process  having  been  changed,  the  recognition 
of  things  did  not  transport  itself  into  time,  and  did  not  find  the 
elements  of  identity  in  relation  to  the  proper  person. 

Melancholia  with  delirium  may  give  rise  to  two  successive 
transformations,  but  this  is  rare.  In  some  cases  there  is  developed 
a delirium  of  persecution  which  assumes  many  of  the  characters 
of  the  delirium  of  persecution  that  we  find  in  paranoiacs  ; these  are 
cases  of  what  Roncoroni  termed  paralypemanias. 

In  other  cases,  and  particularly  those  in  which  the  negativism 
has  been  most  profound  and  the  personality  reduced,  there  springs 
up  a delirium  of  grandeur  which  mingles  itself  strangely  with  the 
delirium  of  lypemaniacal  negation.  Having  lost  the  historic 
thread  of  its  own  existence,  the  new  personality  conceives  the  idea 
of  immortality.  Not  having  been  born,  it  cannot  die,  and  will 
therefore  be  immortal ; if  immortal,  then,  in  logical  sequence,  there 
arises  the  conception  of  divinity.  Such  a case  has  been  described 
as  follows  by  iMagalhaes  Lemos  {Evolution  des  idees  delirantes 
dans  quelques  cas  de  melancholia  chronique  d forme  anxieuse,  XI V^. 
Congres  intern,  de  Medecine,  Porto,  1903).  It  resembles,  in  most 
respects,  cases  of  Seglas  and  others,  and  is  confirmed  by  my  per- 
sonal experience.  The  patient,  always  of  a humble  spirit,  now 
fathoms  the  mystery  of  the  universe  ; he  speaks  of  being  contented 
now,  because  by  dying  he  enters  into  the  joy  of  eternal  rest,  which 


PURE  MELANCHOLIA 


693 


is  supreme  happiness.  Condemned  to  suffer  for  all  mankind 
through  all  eternity,  he  must  be  burned  in  steam-engines,  in  forges, 
and  in  all  the  furnaces  of  the  world  ; he  will  everywhere  take  the 
place  of  oil  and  wood  when  these  fuels  become  exhausted,  and  will 
give  to  the  world  movement,  heat,  and  light.  One  of  my  patients 
thus  became  ‘ Christ  exalted  to  the  glory  of  the  heavens  and  gone 
up  from  human  woe  to  mitigate  the  effects  of  human  misfortune.’ 

Simple  melancholia  as  well  as  delirious  melancholia  takes  two 
forms — the  passive,  which  goes  as  far  as  the  stuporous  state  (melan- 
cholia attonita),  and  the  agitated. 

Melancholia  attonita  presents  various  degrees.  There  is  the 
patient  who  stands  in  the  corner  of  the  room,  with  pale  face,  relaxed 
features,  downcast  eyes,  wrinkled  forehead,  and  a sad  expression. 
He  is  careless  and  negligent  in  his  dress,  his  voice  is  feeble  and 
slow,  his  hands  are  crossed,  and  he  is  timid  and  passive.  Then  there 
is  the  patient  who,  dismayed  by  the  delirious  representations  of 
the  great  sins  he  has  committed,  and  by  hallucinations  of  hell, 
devils,  fire,  is  restless  and  agitated.  The  first  remains  stunned, 
motionless,  with  frightened  face  ; he  offers  a certain  resistance  to 
passive  movements  ; he  expresses  no  desire,  makes  no  demands, 
looks  for  nothing,  obeys  no  one  ; as  a rule  he  declines  food,  is  with 
difficulty  made  to  eat,  and,  in  fact,  most  frequently  he  has  to  be 
fed  through  the  nasal  tube.  He  does  not  move  from  the  spot  to 
empty  the  bladder  or  rectum,  but  wets  and  messes  himself. 
At  length  he  becomes  cyanotic ; the  temperature  at  first  is 
febrile,  then  subnormal,  the  pulse  weak,  the  extremities  cold  and 
oedematous,  and  nutrition  fails. 

Such  a.  state  is  interrupted  by  brief  fits  of  agitation  and  of 
raptus.  If  he  recovers,  he  remembers  the  state  of  his  mind  during 
this  period. 

This  form  of  melancholia  is  much  rarer  than  is  generally  believed. 
Even  very  recent  writers,  like  their  predecessors  of  old,  confound 
stupor  or  stuporous  states  with  melancholia  attonita.  Only  rarely 
does  the  melancholiac  become  katatonic,  and  in  such  cases  there 
is  very  often  a mistake  in  diagnosis.  In  any  case  the  katatonic 
condition  is  an  episodical  fact  related  to  hallucinations  and  the 
episodical  confusion  arising  therefrom. 

Melancholia  agitans  is  represented  in  the  grave  forms  by  agita- 
tion, continuous  and  unvarying  from  the  very  outset,  and  very 
often  animated  by  deliria,  anxiety,  and  grief.  After  a few  or  many 
months,  if  calmness  does  not  supervene,  the  excitement  may 
become  stereotyped,  reproducing  almost  rhythmically  the  same 
movements  and  the  same  phrases. 

One  patient  paces  regularly  through  the  room,  continually 
exclaiming  : ‘ O God,  I am  lost ! What  am  I to  do  ?’  Another,  in 
tones  of  anguish,  repeats  : ‘ I am  damned  !’ 

The  hypochondriac  is  continually  relating  his  sufferings,  and 


694 


PSYCHIATRY 


gives  himself  up  for  lost.  One  young  woman  suffering  from  melan- 
cholia used  to  weep  aloud  from  morning  till  night,  tearing  her 
clothes  and  her  hair  ; another  patient  brought  to  the  asylum  after 
having  attempted  suicide  by  throwing  himself  from  the  window 
of  his  house,  has  been  unable  to  get  out  of  bed  owing  to  multiple  I 
mal-united  fractures,  and  in  his  great  agitation  has,  for  about  four  | 
years,  sat  up  in  bed,  swinging  himself  backwards  and  forwards,  the  I 
while  exclaiming  in  mournful  and  rhythmic  tones  : ‘ O God,  I am  \ 
lost !’  Now  and  again  he  has  more  severe  accessions,  tears  his 
hair,  beats  his  breast,  and  rends  his  clothes.  For  about  a year 
these  fits  of  raptus  have  been  much  rarer,  but  the  attitude  and  the 
exclamations,  now  stereotyped,  have  remained.  Other  patients,  i 
again,  have  incessant  suicidal  impulses. 

The  agitated  form  of  melancholia  may  occur  as  an  episode  in  i 
other  forms,  or  persist  throughout  the  illness  from  a few  weeks  to 
several  years. 

The  lypemaniac  is  almost  always  dangerous.  Along  with  the 
anguish,  eithei  simple  or  associated  with  deliria,  the  idea  of  suicide  | 
always  exists,  with  more  or  less  marked  tendency  to  carry  it  out.  I 
In  this  connection  investigation  in  all  cases  has  resulted  in  con- 
firmation of  the  general  law.  Melancholiacs  may  kill  their  dearest 
ones  (the  mother  her  own  children)  in  order  to  release  them  from  ’ 
the  atrocious  sufferings  of  which  they  believe  them  to  be  victims  ; = 
they  accuse  themselves  of  great  crimes  which  they  have  never  com-  ^ 
mitted  ; they  resign  situations,  believing  themselves  incapable  of  ’ 
discharging  their  duties  ; they  mutilate,  when  they  do  not  kill,  i 
themselves,  in  punishment  of  some  imaginary  offence.  A patient  ! 
m my  chnique  cut  clean  away  his  genitals— penis  and  testicles  ; 
he  recovered. 

With  these  psychic  conditions,  characteristic  of  melancholia, 
whatever  its  form,  coincide  a number  of  somatic  phenomena,  ■ 
some  of  which  are  concomitants  of  the  emotional  states— grief  and  I 
fear  (see  Part  II.)  while  others  have  been  made  known  to  us  j 
through  researches  in  melancholia.  Diminution  of  the  red  blood-  \ 
coipuscles  was  found  by  Seppilli,  and  afterwards  by  others.  Whilst  < 
m mama  there  are  found,  on  an  average,  4,470,000,  in  melancholia 
the  average  is  only  4,000,000  ; the  relation  to  the  leucocytes  is 
usually  maintained.  The  haemoglobin  is  diminished  in  more  than 
half  the  cases. 

In  the  urine  the  phosphates  in  general  are  diminished,  but 
es})ecially  the  alkaline  phosphates,  whilst  indican  and,  according  I 
to  ]\Iario,  scatol  are  increased.  Sometimes  albumin  is  present 
and  tlie  toxicity  of  the  urine  increased.  Nutrition  fails,  the  patients 
lost  weight,  if  not  ahvays — as  Kaes  would  have  it — certainly  very 
freciuently. 

The  blood-serum  is  toxic  from  the  beginning,  especially  in  the 
grave  forms  ; inoculation  of  culture  media  is  often  positive. 


PURE  MELANCHOLIA 


695 


^Muscular  force  is  diminished.  From  a series  of  ergographic 
researches  carried  out  in  my  clinique  by  the  accomplished  Dr. 
Barbato,  the  evident  result  is  a low  level  of  the  ergographic  force, 
which  demonstrates  that  the  affliction  induces  a centripetal  orienta- 
tion of  the  nerve-waves,  and  hence  a great  difficulty  in  the  manifesta- 
tion of  the  centrifugal  currents. 

In  addition  to  the  slight  elevation,  there  are  to  be  observed  m 
the  ergographic  curves  irregularity  and  want  of  harmony,  which  is 
the  mark  of  disintegration. 

All  forms  of  sensibility  are  diminished  ; the  superficial  and  deep 
reflexes  are  normal. 

Appetite  fails,  digestion  is  difficult  ; very  frequently  there  is 
constipation  ; the  breath  is  often  foetid  or  acetonic,  especially  in 
the  acute  period  of  the  disease.  Sexual  instinct  is  extraordinarily 
depressed,  sexual  appetite  almost  always  wanting. 

The  pathological  anatomy  is  uncertain.  Cerebral  anaemia, 
admitted  by  the  greater  number  of  old  and  recent  writers,  is  only 
an  organic  phenomenon  associated  with  the  fundamental  emotional 
state  characteristic  of  melancholia,  and  cannot  be  invoked  as  an 
anatom o-pathological  substratum  of  the  clinical  syndrome. 

Turner  demonstrated  alterations  of  various  degrees  in  the  nerve- 
cells,  and  deduced  arguments  in  support  of  the  viewthat  they  were  due 
to  toxic  impregnation  of  the  nerve-elements  {Brit.  Med.  Jour.,  1901). 

The  researches  of  Stewart  Paton  disclosed  homogeneous  colora- 
tion of  the  cells  (fever  change).  There  are  no  alterations  of  the 
nerve-fibres  or  of  the  neuroglia. 

According  to  Alzheimer,  the  alterations  in  melancholia  can  be 
presumed  rather  than  demonstrated,  all  the  more  so  that  in  the 
present  state  of  our  knowledge  we  cannot  attribute  the  psychic 
phenomena  of  the  disease  to  a given  cerebral  region.  In  the  climac- 
teric melancholias  Alzheimer  found,  in  addition  to  the  changes  in 
the  ganglionic  cells,  a notable  increase  of  neuroglial  fibres  and  pro- 
liferation of  the  cells  in  the  deepest  layers  of  the  cortex. 

Whether  these  alterations  may  be  found  in  one  part  of  the 
cerebral  mantle  more  than  another  only  future  researches  will 
tell.  The  hypothesis  of  Hollander,  who  sought  to  assign  a seat  to 
melancholia,  is  far  from  being  proved.  Hollander  {The  Journal 
of  Mental  Science,  1901),  has  collected  about  fifty  cases,  consisting 
mostly  of  traumatic  lesions  in  the  parietal  region  and  vicinity,  and 
on  these  he  is  inclined  to  base  the  existence  of  a relationship  between 
the  central  region  of  the  parietal  lobe  and  melancholia. 

This  hypothesis  derives  even  greater  probability  from  the  pro- 
found alteration  of  kinaesthesis,  and  also  the  fear  which  characterizes 
simple  melancholia.  It  is  well,  however,  to  observe  that  the 
kinaesthesis  is  altered  also  in  mania,  neurasthenia,  and  progressive 
paralysis.  We  can  at  the  very  most  affirm  that  the  tactile  zone, 


6g6 


PSYCHIATRY 


which  is  the  most  important  centre  of  kinssthesis,  is  chiefly  con- 
cerned  in  melancholia. 


The  cBtiology  is  the  same  as  in  all  the  other  acute  psychoses 
have  to  deal  with  predisposition  from  heredity  and  other  causes 
which  reduce  the  nutritive  and  phagocytic  power  of  the  organism 
(previous  illness,  exhausting  diseases,  mental  worries-especially 
the  death  of  dear  ones— intense  fears,  insufficient  food,  hcemor- 
rhages).  All  these  causes  act  by  producing  a state  of  hyponutrition 

of  the  central  nervous  system.  Involution,  asserted  by  Kraepelin 
IS  not  constant.  ^ ’ 

orru  certainly  much  more  frequent  in  the  fourth  and 

^ 3-nd  the  reason  is 
not  difficult  to  understand  when  one  remembers  that  these  decen- 
naiies  represent  the  age  of  the  strongest  conflicts  and  the  keenest 
struggle  for  existence,  m which  humanity  often  succumbs.  This 
IS  the  age  in  which  fears  and  griefs  are  mostly  accumulated,  often 
not  counterbalanced  by  the  joy  of  victories  that  give  self-con- 
fidence, and  by  the  consciousness  of  vigour.  The  melancholiac 
IS  a weakling,  not  an  involute.  Certainly  in  the  fifth  decennary 
the  signs  of  organic  involution  frequently  make  their  appearance, 
but  the  very  large  number  of  melancholiacs  between  the  ages  of 
hirty  and  fifty  confers  no  value  on  the  assertions  of  those  who 
regard  melancholia  as  a disease  of  involution.  It  is  rare  in  the 
young,  because  in  early  life  the  exuberance  of  spirit  and  the  limited 
experience  of  difficulties  encourage  that  reliance  upon  the  personal 
vigoui  which  IS  to  lead  victoriously  to  the  desired  goal 

For  similar  reasons  it  is  less  frequent  in  men  than  in  women. 
It  often  coincides  with  the  climacteric  period  (presenile  melancholia) ; 
m le  ve^  young  it  is  usually  the  effect  of  excessive  onanism. 
Women  who  are  pregnant,  and  especially  those  who  are  so  for  the 
rst  time,  supply  a notable  proportion  of  melancholiacs  (anxiety 
f-  P®  circulatory  disturbances,  pregnancy,  intoxica- 

tions). Chronic  alcoholism  is  not  alien  to  its  {etiology. 

The  diagnosts  of  simple  melancholia  is  comparatively  eas\-, 
xcept  with  regard  to  neurasthenia.  In  the  latter  the  depression 

r is  inter- 

rupted by  phases  of  cheerfulness ; the  psychic  arrest  is  much  less, 
and  concern  for  one’s  own  health  predominates.  In  melancholia 

w anguish,  persistent  and  desperate,  and 

V i etchedncss  of  the  personality  are  characteristic. 

TliP  H I '®  ‘i’c  diagnosis  presents  fewer  difficulties, 

e dehiia  described  are  almost  exclusive  features  of  melancholia, 

nn  iZZZZ  y ^’'®  possibility  that  the  melancholia  is 

rnelm  c ml-  'Z r ® P"®8"®®®i''®  Paralysis.  In  the  latter,  along  with 
melancholic  deliria,  we  meet  with  mental  decadence,  some  of  the 


PURE  MELANCHOLIA 


697 


somatic  phenomena  of  progressive  paralysis,  and  sometimes  the 
automatic  rising  of  some  grandiose  idea,  which  seems  out  of  place 
in  the  midst  of  all  the  melancholic  formations  of  that  period  of  the 
disease. 

less  easy  is  the  diagnosis  between  melancholia  attonita 
and  stupor,  or  melancholic  mental  confusion.  Here  the  history 
of  the  initiation  of  the  disease  affords  more  assistance  than  the 
state  of  the  muscles  (relaxation  or  hypertonia),  or  of  the  pupils 
(dilatation,  contraction,  or  rigidity)  which  may  be  found  alike  in 
both  diseases.  If  the  malady  commences  with  vivid  hallucinations 
we  have  probably  to  deal  with  the  melancholic  variety  of  hallu- 
cinatory insanity.  The  typical  forms  of  katatonia  are  not  present 
in  melancholia,  except  as  fleeting  episodes. 

The  difficulties  in  the  way  of  deciding  whether  a first  attack 
of  melancholia  is  a pure,  periodical,  or  alternating  psychosis,  are 
often  insuperable.  The  occurrence  at  a very  early  age  would  tend 
to  the  exclusion  of  the  pure  form,  and  that  without  sharing  in  the 
exclusiveness  of  Kraepelin.  The  circular  and  periodical  forms  are 
not  very  rare  in  the  fourth  and  fifth  decennaries  of  life.  Marked 
heredity  and  psycho-somatic  degenerative  stigmata  give  us  cause 
to  fear  the  beginning  of  the  disease  in  the  periodic  and  circular  forms. 

The  prognosis,  for  the  foregoing  reasons,  presents  great  diffi- 
culty to  the  clinician,  because,  confronted  by  a first  attack,  he 
finds  it  no  easy  matter  to  give  a decided  opinion  as  to  its  nature— 
whether  it  is  pure  or  not  ; then,  admitted  that  he  has  succeeded 
in  recognising  it  as  a pure  form,  the  question  arises,  Is  it  one  of 
those  which  are  curable  ? The  age  of  the  patient  is  often  no 
positive  aid,  because  melancholia  is  cured  at  all  ages  ; even  in  the 
aged  recovery  is  not  rare.  Advanced  involution,  confusion  asso- 
ciated with  deliria  and  hallucinations,  rapid  mental  decadence, 
automatism,  and  stereotypism  are  all  evil  omens.  Melancholia 
attonita  is  more  grave  than  the  simple  and  delirious  forms.  Intense, 
sorrowful  agitation  is  always  an  alarming  phenomenon.  Intel- 
lectual obsessions  aggravate  the  prognosis. 

Some  authorities  consider  the  prognosis  to  be  always,  or  almost 
always,  grave  when  the  case  is  regarded  as  either  periodical  or 
maniacal-depressive  insanity.  I look  upon  Kraepelin  s statistics, 
showing,  out  of  thousands  of  cases  of  mania  and  melancholia,  only 
one  in  which  there  was  no  relapse,  as  being  greatly  exaggerated. 

Roncoroni  and  Sanna  Salaris  from  1891  to  1896  observed  eleven 
cases  of  melancholia  which,  up  till  1901,  had  not  relapsed.  I have 
observed  many  cases  in  which  there  has  been  relapse  after  a period 
of  ten  years.  Now,  it  is  clear  that  a relapse  after  eight,  ten,  or 
fifteen  years  cannot  be  put  in  relation  with  the  first  attack,  unless 
to  indicate  that  it  is  the  worries  of  life  that  prepare  the  conditions 
favourable  to  a repetition  of  the  disease. 


6g8 


PSYCHIATRY 


The  lady  who  presented  the  metabolism  of  personality  de- 
scnbed,  was  >H  for  the  first  time  in  1883,  at  the  age  of  thirty-six 
ais  She  fell  ill  again  of  the  same  form  in  1896;  the  attack 
hTahli  In  1904,  she  was  enjoying  the  most  perfect 


tieatment  of  melancholic  patients  bristles  with 
aimculties  and  dangers. 

The  suicidal  tendency,  and  the  refusal  to  take  food  are  two 
menaces  for  the  physician,  whose  first  duty  it  is  to  put  the  patient 
under  constant  and  careful  observation. 

Recreations  and  travels  are  of  assistance  in  only  a few  cases 
of  simple  me  anchoha.  As  a rule,  everything  that  affords  pleasuie 
m the  normal  state  is  received  dolefully  by  the  melancholiac,  and  is 
erefore  injurious.  At  the  beginning  of  the  disease  good  results 
are  obtained  from  lavage  of  the  intestines  and  the  stomach,  and 
rom  lypodermic  transfusions,  especially  when  phenomena  of 
intoxication  appear  strongly  evident.  This  practice,  followed 
m my  clmique  in  recent  cases— and  such  cases  are  becoming  less 
nuinerous  (observations  by  Galante)-has  given  good  results. 

Ihe  diet  should  be  varied:  milk,  vegetables,  leguminous  and 
farinaceous  foods,  with  flesh  meat,  ought  to  prevail. 

Tepid  baths  in  the  excited  and  agitated  forms,  light  hydro- 
erapy  with  douches  in  the  stuporous,  torpid  forms,  galvanization 

* 4-1  j general  faradization  by  the  Rockwell 

method,  are  good  helps. 

Open-air,  sunlight,  excursions  into  the  country,  short  readings 
01  simple  games  (in  the  mild  forms),  are  always  preferable  to  the 
indoor  atmosphere  and  to  inaction.  From  this  point  of  view 
good  asylums  and  sanatoria,  provided  with  fields  and  gardens,  are 
preferable  to  the  treatment  of  the  patient  at  home  when  favour- 
able  conditions  do  not  prevail  there. 

In  some  cases  rest  in  bed  is  helpful, -but  then  hydrotherapy, 
massage,  and  electrotherapy  should  be  employed. 

Phaimaceutical  remedies  have  a double  object — to  raise  the 
general  conditions  and  the  arterial  pressure,  to  lessen  the  mental 
pain  and  the  insomnia.  The  first  is  attained  by  the  use  of  ferru- 
ginous medicines,  arsenic,  cod-liver  oil,  glycero-phosphates,  strych- 
nine, digitalis,  adonis  ; for  the  anguish  and  insomnia,  opium  in  doses 
incieasing  to  i giamnie  a day,  injections  of  morphine  to  the  extent 

o b centigrammes  in  the  twenty-four  hours,  cannabis  indica,  and 
hashish,  will  be  useful. 

If  file  patient  refuses  food  it  is  necessary  to  have  immediate 
lecourse  to  artificial  feeding  through  the  nasal  tube. 

of  tl  general  exercise  a depressing  action  on  the  function 

le  'eait  and  aiteiial  tension,  and,  although  recommended  bv 
ome  ciuthois,  are  in  my  experience  injurious. 


PURE  MELANCHOLIA 


699 


The  periodical  forms  of  mania  and  melancholia  almost  always 
preserve  the  same  characteristics  and  maintain  the  type  unvaried, 
save  for  the  sometimes  progressive  aggravation  of  the  attack  in 
its  intensity  and  duration. 

Clinical  observation,  free  from  preconceptions,  compels  us  to 
consider  the  periodical  forms  of  insanity  apart  from  maniacaTdepies- 
sive  insanity.  One  cannot  confound  maniacal-depressive  insanity 
with  mania  or  melancholia  which,  during  relapses,  always  presents 
the  same  characters,  or  with  any  other  form  of  insanity  which,  in 
its  recurrence,  preserves  its  physiognomy.  Confusion  is  not  justified 
from  either  the  clinical  or  the  psychological  side.  My  point  of  view 
in  this  matter  coincides  with  that  of  Hitzig,  Pilcz  {Die  periodischen 
Geistesstor ungen,  Jena,  1901),  and  many  others. 

The  attacks  of  melancholia,  as  well  as  those  of  mania,  in  the 
respective  subjects,  are  very  similar  to  pure  attacks— that  is  to 
say,  without  concomitants  of  contrary  form.  The  maniacal  attack 
begins  and  finishes  as  mania,  gradually  settling  down  into  the 
normal  state,  and  so  with  the  melancholic  attack.  The  duration 
of  the  attack  varies  very  much  in  different  cases,  sometimes  lasting 
only  a few  days,  sometimes  extending  over  a year  and  more,  and 
usually  with  each  fresh  attack  there  is  a tendency  to  its  prolongation, 
whilst  the  type  is  preserved. 

The  mild  type  of  mania,  for  example,  is  often  preserved  in  many 
successive  attacks,  but  in  time  it  frequently  assumes  the  char- 
acteristics of  the  typical  form.  Usually  in  the  same  individuals 
the  attacks  correspond  to  certain  seasons,  some  particularly  to 
spring,  others  to  autumn.  Many  patients  know  that  they  will 
fall  into  the  morbid  state  in  April,  in  August,  or  in  October,  and 
they  consult  the  doctor  beforehand,  in  the  hope  of  being  able  to 
prevent  the  recurrence  of  the  attack. 

It  has  been  much  discussed,  especially  by  forensic  physicians, 
whether  the  free  interval  between  two  attacks  ought  to  be  con- 
sidered as  one  cf  perfect  mental  sanity. 

Accurate  psychological  analysis  of  many  of  these  patients  has 
convinced  me  that  unless  the  attack  is  followed  by  signs  of  mental 
decadence,  which  is  very  slow  in  confirming  itself,  the  free  interval 
coincides  with  complete  mental  sanity — that  is,  if  we  except  signs 
of  psychic  degeneration  or  of  anomalous  character  existing  previous 
to  the  attack,  as  often  happens. 

At  the  very  utmost  we  may  speak  of  a great  cerebral  vulner- 
ability which  is  usually  increased  by  repetition  of  the  attacks. 

There  is  nothing  to  be  added  with  respect  to  the  nosographical 
picture  of  the  disease,  the  characters  of  which  are  in  all  their  grada- 
tions the  same  as  those  of  mania  and  melancholia,  even  in  their 
smallest  particulars. 

We  possess  no  data  enabling  us  when  dealing  with  a first  attack  of 
melancholia  or  of  mania  to  foretell  whether  it  is  a pure,  a periodical, 


700 


PSYCHIATRY 


or  a circular  form.  One  sole  indication,  and  that  not  in  all  cases, 
is  derived  from  the  knowledge  of  the  mobile  character  of  the  patient 
previous  to  the  attack  (frequent  and  irrational  alternations  of  the 
mental  disposition). 

The  one  important  feature  is  in  the  prognosis,  which  is  grave  • 
but  this  can  only  be  reduced  to  the  concrete  after  a year  or  so.’ 
When  the  disease  is  repeated  a second  time,  especially  if  the  first 
attack  has  been  of  long  duration,  one  may  be  almost  certain  that 
It  will  be  repeated  at  determined  periods.  It  has  happened  occa- 
sionally that  the  disease  has  missed  a season,  and  then  resumed 
its  course  in  the  following  year. 

Sometimes  the  attacks  do  not  return  at  determined  and  almost 
equal  intervals,  but  occur  very  irregularly,  and  as  the  result  of  dr- 
cumstances  that  are  not  always  discoverable. 

In  some  the  cerebral  vulnerability  is  such  that  the  smallest 
opposition  may  determine  the  onset  of  the  attack. 

I have  patients  who  remain  even  more  than  a year  in  the  fixed 
and  uniform  surroundings  of  the  asylum,  behaving  like  sane  persons, 
and  are  thus  protected  from  the  customary  attack,  whilst,  after 
discharge,  they  fall  back  into  their  former  condition  through  trivial 
causes  (opposition  or  small  quantities  of  alcohol).  These  forms 
may  be  better  described  as  recurrent  than  as  periodical  forms. 

It  must  be  clearly  understood  that  I intend  to  speak  here  only : 
of  mania  and  periodical  or  recurrent  melancholia.  Periodical  insanitv  ' 
being  an  artificial  type  of  disease,  the  term  is  destined  to  disappear  ' 
from  the  nomenclature.  Many  distinct  morbid  forms  return  at  ^ 
more  or  less  regular  intervals  through  constitutional  and  other! 
individual  peculiarities,  yet  do  not  on  that  account  lose  their 
clinical  character.  The  accentuation  of  the  hysterical  character — 
extending  even  to  attacks  of  true  insanity — coincident  with  men-  . 
struation,  is  a form  of  periodical  insanity,  just  as  epileptic  insanity  i 
may  be  periodical.  Attacks  of  dipsomania  are  often  periodical,  and  i 
similar  to  the  periodical  or  recurrent  attacks  of  hallucinatory  mental  ! 
confusion.  All  these  morbid  forms  cannot  be  grouped,  either  i 
through  their  genesis  ^ or  their  nosographical  characters,  with  ^ 
periodical  mania  or  periodical  melancholia.  The  periodic  return  of 
any  psychosis  whatsoever  has  its  origin  in  the  temperament  of  the 
individual,  and  occurs  in  the  most  diverse  forms  of  insanity. 


CHAPTER  XV 


MANIACAL-DEPRESSIVE  INSANITY 

The  typical  form  of  maniacal- depressive  insanity  consists  in  an 
attack"^  divided  into  two  periods,  the  one  plainly  maniacal,  the 
other  as  plainly  melancholic. 

It  may  begin,  indifferently,  with  mania  or  melancholia  ; it  may 
exhibit  the  most  diverse  degrees  of  intensity  ; it  lasts  from  some 
weeks  to  two  years  and  longer. 

If  the  disease  has  commenced  with  the  melancholic  form,  the 
symptoms  disappear  after  a stationary  period.  The  state  of 
inhibition  diminishes ; the  field  of  ideas  is  gradually  enlarged ; the 
dawn  of  the  former  activity  reappears ; the  deliria,  if  there  were 
any,  lose  their  colour ; the  mind  is  less  oppressed  and  more  hopeful ; 
by  degrees  sleep,  appetite,  and  former  habits  return,  and  thus 
little  by  little  a state  very  similar  to  the  normal  is  reached.  Yet, 
when  the  patient  seems  restored  to  former  conditions,  the  scene, 
in  the  course  of  a few  days  or  weeks,  changes.  The  one-time 
sufferer  from  melancholia  appears  more  hilarious  than  usual,  more 
loquacious,  more  meddlesome,  more  enterprising,  no  longer  de- 
liberate, sometimes  audacious,  sarcastic,  irritable,  intolerant, 
aggressive.  Thus  develops  the  maniacal  attack,  which  assumes 
all  the  previously  described  characters  and  grades  of  mania,  and  it 
may  last  as  long  as  the  melancholic  attack,  sometimes  much  longer. 

Unlike  the  purely  circular  form,  this  may  be  followed  by  a 
period  of  mental  decadence,  especially  when  the  maniacal  attack 
is  long  and  intense.  In  other  cases  recovery  proceeds  slowly,  and 
is  either  complete  or  attended  by  some  little  deficit.  In  these 
typical  cases  no  further  attack  occurs  for  many  years. 

In  some  cases  the  inversion  of  the  morbid  type  takes  place  only 
after  a very  long  interval  of  time.  After  a long  period  of  perfect 
sanity  a patient  in  my  private  clinique  was,  in  1891,  seized  with 
a maniacal  attack  which  lasted  about  nine  months  ; a lypemaniacal 
attack  occurred  in  1900.  Both  attacks  reached  the  middle  grade 
of  intensity,  both  had  the  same  duration. 

One  might  be  led  to  suppose  that  these  attacks,  separated  by 
such  long  intervals  of  mental  sanity,  might  be  connected  with  one 


702 


PSYCHIATRY 


Fig.  83. — Periodical  Mania. 

V-v  W V_y  y V,J7 


Fig.  85. 


Fig.  86. 

Figs.  85  and  86. — Maniacal-depressive  Insanity. 


Fig.  87. 


Figs.  87  and  88. — Mixed  Form. 


^ 


Fig.  89. 


Fig.  90. 


^ 

w w v_y 


Fig.  91. 

Figs.  89,  90,  and  91 Circular  Insanity. 


MA  NIA  CA  L-DEPRESSI VE  I NS  A NIT  Y 703 

another,  thus  constituting  a single  morbid  form.  In  each  attack 
the  physical  conditions  change  with  the  psychic  ones.  The  blood- 
pressure,  the  haemoglobin,  the  number  of  red  corpuscles,  the  respira- 
tion, the  muscular  force,  the  sensibility,  become  altered,  and  are 
found  in  the  respective  attacks  of  circular  insanity  to  be  the  same 
as  in  pure  mania  and  pure  lypemania. 

In  other  cases  two  or  three  attacks  occur  at  intervals  of  a year 
or  so,  all  showing  the  same  features — pure  attacks  of  mania  or  of 
melancholia  ; and  after  the  second  or  third  attack  there  follows 
the  exalted-depressive  one,  which  represents  a graver  form  than 
simple  m^elancholia  or  relapsing  mania. 

The  attack  of  exalted-depressive  insanity  may  be  continuous, 
or  broken  in  two  by  a lucid  interval,  of  longer  or  shorter  duration, 
even  lasting  about  a year. 

In  circular  insanity  the  alternating  attacks  are  repeated  in- 
definitely. 

The  gravest  form  of  this  sub-group  is  that  which  gives  very 
short  truces,  inasmuch  as  the  psychic  life  is  caught  in  the  gearing 
of  a series  of  maniacal  and  lypemaniacal  attacks,  from  which  the 
sufferer  very  rarely  succeeds  in  freeing  himself. 

The  forms  which  circular  insanity  may  assume  are  various. 
The  attacks  of  mania  and  lypemania  may  follow  each  other  alter- 
nately, without  any  truce  or  free  interval ; the  single  attacks  of 
mania  and  lypemania  may  be  separated  by  a free  interval,  or 
there  may  be  complete  exalted-depressive  attacks  separated  by 
free  intervals  (Ritti  and  others). 

When  the  attacks  are  interrupted  by  free  intervals,  especially 
if  these  are  not  very  short,  intelligence  may  be  preserved  sufficiently 
well  for  a much  longer  time  than  occurs  in  the  case  of  a prolonged 
attack  of  mania  or  melancholia. 

The  diagrams  which  I give  illustrate  very  clearly  the  different 
forms  of  periodical  insanity  and  of  exalted-depressive  insanity  in 
all  the  varieties  which  correspond  to  circular  insanity. 

We  have  nothing  to  add  to  the  pathology  of  this  form  except 
that  it  is  rooted  in  grave  psychopathic  heredity  and  in  anomalies 
of  the  character. 

The  prognosis  is  grave.  Mental  enfeeblement  follows  much 
more  slowly  than  in  the  pure  form. 


CHAPTER  XVI 


SENSORY  INSANITY 

Under  this  name  are  included  all  those  psychopathic  states  which 
begin  with  hallucinations  and  illusions,  no  matter  whether  these 
sensory  disturbances  dominate  the  scene  during  the  whole  course 
of  the  disease  or  disappear  at  the  beginning  of  it,  leaving  syndromes 
which  it  would  be  a mistake  to  consider  as  particular  forms  of 
disease,  since,  in  point  of  fact,  they  form  with  the  sensory  disturb- 
ances one  single  whole,  clinically  and  psychologically  inseparable. 
The  elevation  of  these  syndromes  to  pathological  dignity  was  only 
possible  in  so  far  as  the  connecting-links  between  the  various  psycho- 
pathic facts,  and  also  that  logical  succession  of  symptoms  a know-  ’ 
ledge  of  which  is  important  in  pathological  psychology,  escaped  our 
notice.  < 

We  have  had  described  to  us  amentia,  acute  dementia,  dementia  ' 
prsecox,  katatonia,  stupor,  and  mental  confusion,  and  these  in  ^ 
most  instances  are  only  syndromes,  particular  attitudes  of  the  ! 
disease,  not  the  disease  in  its  entirety;  they  represent,  also,  a ^ 
changeable  phase,  a chronological  feature  of  a complex  psychosis. 
Now,  these  syndromes  which  represent  a part  of  the  morbid” picture  ; 
cannot  rise  to  the  dignity  of  psychopathic  figures  by  themselves,  j 
They  must  be  framed  in  the  picture  which  includes  them  all.  The  | 
disease  must  be  examined  from  the  beginning ; and  just  as  in  a gi*eat  \ 
number  of  cases  a melancholic  phase  often  precedes  the  commence-  i 
ment  of  mania,  thus  justifying  the  inclusion  of  many  manias  and  ) 
melancholias  in  the  one  disease  called  by  Kraepelin  maniacal- 
depressive  psychosis,  so  in  the  same  way  those  syndromes  ought 
to  be  included  in  one  description— for  this  reason,  that  the  disease 
commences  with  the  same  phenomena,  and  it  is  only  in  its  later 
development  that  it  presents  that  great  variety  of  attitudes  which 
imprint  on  it  a particular  differential  character  in  the  successive 
phases. 

This  character  might  justifiably  give  its  name  to  the  disease 
if  one  could  consider  it  as  disjoined  from  the  facts  which  precede 
it ; but,  if  the  various  characters  represent  one  inseparable  whole, 
then  any  description  whatsoever  of  syndromes  appears  to  be 
artificial,  and  does  violence  to  the  logic  of  the  facts.  ■■ 

704  < 

I* 

i 


SENSORY  INSANITY 


705 


What  do  we  learn  when  we  have  had  an  opportunity  of  observing 
all  these  morbid  forms  at  their  very  commencement,  or  when  we 
go  back  over  the  history  of  the  disease  and  reconstruct  it  after  a 
strict  and  searching  investigation  ? The  almost  constant  fact  is 
the  hallucinatory  explosion  of  the  disease.  It  presents  different 
characters  in  succession,  assuming  other  forms  which,  whether 
dementia  or  katatonia,  are  more  sensible  and  persistent,  and  we 
lose  sight  of  the  hallucinations,  which  in  the  fully-developed  disease 
pass  into  the  second  rank,  and  no  longer  dominate  the  morbid 
picture,  or  else  are  regarded  as  accidental,  but  not  necessary, 
phenomena  in  a disease  already  developed  ; and  hence  we  speak 
of  dementia  and  katatonia  as  diseases  in  themselves,  but  we  are 
no  more  justified  in  doing  so  than  we  would  be  entitled  to  speak 
of  hemiplegia  as  a disease  without  taking  into  account  the  destruc- 
tive focus  which  produces  it,  or  to  raise  to  nosological  dignity 
malarial  anaemia  without  having  regard  to  the  infection  which 
produced  it,  and  to  the  connection  which  exists  between  the  different 
facts  of  the  disease. 

Neglect  of  the  mode  of  development  of  these  complex  symptoms 
has  been  the  cause  of  great  confusion — a confusion  tending  to  make 
itself  felt  more  and  more  every  day,  and  greatly  hindering  that 
intelligent  knowledge  of  things  which  arises  from  keen  observation, 
free  from  that  subjectivism  which,  having  an  air  of  originality, 
disconcerts  the  regular  progress  of  scientific  thought. 

Kinaesthetic,  tactile,  auditory,  and  visual  hallucinations  have  a 
great  disintegrating  power  over  the  personality.  The  latter  possesses 
an  index  of  resistance  differing  enormously  in  various  subjects,  and 
when  it  is  decomposed,  the  fragments  either  remain  isolated  or 
become  grouped  together  again,  giving  rise  to  other  compositions 
which  become  grafted  upon  the  nature  of  the  patient,  like  the 
paranoidal  formations,  katatonic  manifestations,  etc. 

In  the  classification  I have  separated  mental  confusion  from 
sensory  insanity  because  in  some  cases  of  the  former,  in  retracing 
the  history  of  the  disease,  I have  not  succeeded  in  satisfying  myself 
as  to  the  hallucinatory  beginning,  and  on  that  account  I do  not 
deny  that  some  neurasthenic  states  may  proceed  the  length  of 
giving  a confusional  svndrome  or  so-called  simple  dementia  praecox 
without  hallucinations,  or  with  late  sensory  disturbances. 

Whilst  in  a great  number  of  mental  diseases  hallucinations 
are  secondary,  although  very  impotant,  phenomena  in  sensory 
insanity,  on  the  contrary,  they  are  the  radical  and  substantial 
phenomena,  and  consequently  they  provoke  abnormal  intellectual 
and  affective  states. 

Clinical  observation,  on  which  this  conception  of  sensory 
insanity  is  founded,  extended  to  particular  morbid  forms  con- 
sidered till  now  as  diseases  per  se  (acute  dementia,  dementia 
praecox,  mental  confusion,  etc.),  though  preserving  the  particular 

45 


7o6 


PSYCHIATRY 


clinical  dignity  of  the  psychosis  compels  us  to  distinguish  it  into ' 
several  sub-groups. 

The  first  is  constituted  by  what  I would  call  illusional  or  per- 
ceptive  insanity.  It  consists  in  an  illusory  perception  of  one’s  ' 
own  physical  person,  or  that  of  others.  Illusory  perception,  whilst 
it  furnishes  material  for  a false  judgment,  disintegrates  the  per- 
sonality, taking  it  almost  by  surprise. 

As  a rule,  it  occurs  in  neuropathic  individuals,  or  in  persons 
whose  brains  have  become  vulnerable  owing  to  heredity  or  excesses, 
and  in  whom  even  a slight  sensory  disorder  is  sufficient  to  disturb 
the  whole  psychic  union. 

The  following  are  a few  examples  of  it  ; 

Observation  XXIII.— M.  M.,  a nurse,  about  twenty-four  years 
old,  had  always  enjoyed  good  health,  and  was  bringing  up  with  great 
care  a child  of  Prince  X.  in  Palermo.  ! 

One  day  she  was  told  that  a brother,  whom  she  had  not  seen  for  a ' 
long  time,  had  come  to  visit  her.  Anxious  to  meet  him  again,  she  went  i 
out  into  a hall  adjoining  the  room,  but  stood  dismayed  on  beholding  her  I 
brother,  not  in  his  true  stature,  but  shorter  in  height  by  a good  many  1 
inches.  : 

The  illusion  persisted.  The  young  woman,  not  being  able  to  calm 
herself,  put  a great  many  questions  to  her  brother  as  to  the  reason  for 
such  a change  in  his  height,  but  it  was  impossible  to  convince  her  that  : 
there  was  no  truth  in  what  she  asserted.  That  day  she  remained  in  a 1 
state  of  inhibition,  was  depressed,  dubious,  stupefied.  This  state  became 
more  pronounced,  phenomena  of  disintegration  appeared  on  the  scene,  ' 
and  even  went  the  length  of  real  mental  confusion,  on  account  of  which 
she  had  to  be  sent  to  the  asylum.  She  recovered  after  a month  or  so.  ,j 

Observation  XXIV. — A neurastheniac  one  day  looked  in  the  mirror,  ! 
but  no  longer  recognised  his  own  physiognomy,  so  much  changed  did  it  I 
appear  to  be.  From  that  moment  there  was  established  a state  of  i 
anguish  with  psychic  arrest,  and  after  a few  days,  during  which  he  i 
was  depressed,  preoccupied,  and  full  of  anxiety,  he  came  to  tell  me  his  ; 
case.  That  false  image  supplied  the  germ  of  a depressive  delirium  i 
which  lasted  a few  months.  He  got  better,  and  I have  not  seen  him  since.  ( 

Observation  XX\  . — A.  N.,  a girl  in  her  sixteenth  year,  belonging  to  a 1 
neuropathic  family,  delicate,  rather  good-looking,  a little  proud  of  her  ' 
beauty,  slender,  and  very  excitable,  was  one  day  looking  at  herself  in  the 
minor,  when  she  noticed  that  her  mouth  was  turned  to  one  side,  that 
hei  nose  had  become  longer,  and  that  her  ears  were  not  on  the  same  level. 
Alaimed,  she  turned  her  eyes  from  the  glass,  but  for  confirmation  of 
uhat  she  had  seen  she  decided  to  re-examine  herself  in  the  glass,  and 
ha\  mg  done  so  came  away  with  the  same  impression,  became  melan- 
cholic, irritable,  gloom}’,  indolent,  and  remained  for  hours  before  the 
rnirror  choked  with  sobs.  She  was  sent  to  the  country,  where  she  recovered 
alter  energetic  tonic  treatment. 

Such  cases  as  these  are  not  rare.  They  cannot  be  confused  i 
v\ith  any  of  the  known  psychopathies.  They  cannot  be  mistaken  ' 
foi  confusion,  because  this  phenomenon  is  either  entirely  wanting  : 
oi  ib  secondai'}’  and  late  ; nor  for  melancholia,  because  the  painful 


SENSORY  INSANITY 


707 


state  of  mind  is  relatively  insignificant,  and  the  afflictive  coercion 
of  the  intellect  is  determined  a false  perception,  which  is  the 
primary  fact,  and  takes  the  consciousness  surprise  in  the  fulness 
of  its  vigour  ; nor  for  paranoia,  because  here  we  do  not  observe 
delirium,  but  a simple  orientation,  with  preoccupying  concentration 
on  that  which  has  been  falsely  perceived.  It  is  not  a simple  hallu- 
cinatory episode  of  a neuropathic  constitution,  for  in  all  these  cases 
we  have  to  deal  with  a true  symptomatic  complexity  whose  first 
appearance  is  clearly  definable. 

In  every  case  I have  observed  the  neuropathic  constitution  and 
neurasthenic  phenomena.  Recovery  is  not  the  most  frequent 
result. 

In  the  second  sub-group  are  included  subjects  of  hallucination 
of  good  mental  constitution,  in  whom  the  hallucinations,  being 
neither  intense  nor  terrifying,  but  varied,  may  be  repeated  for  a 
very  long  time  without  disturbing  their  mental  organization  and 
conscious  personality. 

Here  is  an  example  of  it,  and  such  as  is  not  commonly  met 
with  : 

Observation  XXVI. — The  case  is  that  of  a very  intelligent  and 
cultured  gentleman  who  for  a few  years  has  been  tormented  by  hallucina- 
tions which  we  may  call  reflex,  auditory,  and  visual.  All  the  words  and 
other  sounds  which  he  hears,  especially  if  loud,  such  as  the  cries  of  street 
hawkers,  are  repeated  many  times  in  succession  like  an  echo,  and  then 
disappear. 

In  consequence  the  course  of  his  thought  and  his  speech,  often 
broken  in  upon  by  this  repetition  and  confused  blending  of  calls,  words, 
and  sounds,  is  rendered  very  difficult,  and  the  actual  perception  of  what 
surrounds  him  is  equally  difficult  on  account  of  the  obstacle  which  comes 
into  the  field  of  perception  from  the  preceding  perceptions,  whose  survival 
he  recognises  to  be  nothing  but  the  echoes  of  what  he  really  hears 
and  sees.  From  time  to  time  in  the  evening  and  the  silence  of  the 
night  these  echoes  are  repeated  more  feebly  ; but  he  knows  that  they 
are  only  the  repetition  of  the  diurnal  phenomena,  and  pays  no  heed  to 
them,  but  struggles  continually  in  order  to  keep  himself  fully  conscious, 
and  to  keep  a firm  grasp  of  his  ideas  and  convictions.  Now  and  then, 
however,  he  suffers  so  much  from  them  as  to  have  true  states  of 
anguish  and  excitement,  from  which  he  recovers  after  a few  weeks, 
returning  to  the  previous  state.  Twice  he  has  suffered  real  attacks 
of  acute  confusion  with  marked  logorrhoea  and  incoherency,  along  with 
excitement,  restlessness,  and  insomnia,  from  which  also  he  recovered  in 
little  more  than  a month,  returning  gradually  to  what  he  was  before — 
always  troubled  by  the  usual  echoes. 

That  he  preserves  his  pyschic  personality  entire  or  almost  entire, 
except  for  a certain  tendency  to  the  interpretation  of  the  phenomenon,  is 
clearly  demonstrated  by  the  following  letter  which  I received  from  him  : 

' ‘ Signor  Professor, 

‘ Serious  afflictions  caused  my  disease,  afflictions  which  in 
themselves  were  perhaps  incapable  of  causing  such  serious  injury  in  others, 
but  in  me,  endowed  by  Nature  with  an  exquisitely  sensitive  heart,  with 
a tenaciously  reflective  intelligence,  and  a fervid  imagination,  however 

45—2 


7o8 


PSYCHIATRY 


i 


well  belanced,  were  sufficient  to  give  rise  to  serious  disturbances,  whicli 
still  persist,  though  in  a less  degree.  j 

‘ The  disease  manifested  itself  in  1888,  and  the  first  phenomenorj 
observed  by  me  was  sudden  tension,  or  rather  an  instantaneous  attacli 
of  cramp  in  the  principal  muscle  of  the  brain,  producing,  as  it  were,  th( 
effect  of  a bowstring  violently  snapped,  and  I distinguished  even  th( 
noise  of  it,  so  much  so  that  I took  my  head  between  my  hands,  noi| 
knowing  what  had  happened  to  me  ; I foresaw,  however,  that  it  wa^i 
something  very  serious.  ! 

‘ From  that  day  forth,  without  my  being  conscious  of  it,  fancy,  nc| 
longer  governed  by  the  will  and  directed  by  the  intelligence,  hastened 
always  on  to  the  formation  of  phantasmagorias,  which  I believed  positive! 
realities.  ^ I wanted  to  read,  but  the  phantasmagorias,  stronger  thar 
my  will,  insidiously  and  persistently  undermined  my  attention,  attracting 
it  towards  themselves,  and  I remained  abstracted  for  whole  hours  without 
attending  to  what  I was  reading. 

‘ In  proportion  as  the  unconscious  predominated  over  the  conscious 
ego,  the  echoes  continued  to  develop  in  all  my  members — eyes,  legs, 
arms,_  hands,  and  more  especially  in  my  ears — without  my  being  able  to 
explain  why.  As  I saw  all  my  movements  repeated  in  others,  I ran 
hither  and  thither  seeking  to  hide  myself  in  the  innermost  recesses  of  the 
house,  believing  that  all  were  set  against  me ; but  I perceived  afterwards 
that  they  were  my  own  echoes,  revealing  to  me  things  which  had  no 
existence. 


‘ I had  already  experienced  great  mental  worry,  and  now  to  the  worry 
was  added  fancy.  Even  in  my  waking  moments  I dreamt  of  courts  of 
justice  and  courts  of  assize.  I became  so  much  absorbed  in  these  phantas- 
rnagorias  alone  that  for  entire  days  my  wa3Avard  fancy,  with  all  the 
vividness  of  reality,  led  me  through  the  harrowing  experience  of  the 
criminal  dock,  the  judgment,  the  condemnation.  Then  my  room' 
became  transformed  into  a cell ; the  acrid  smell  of  the  prison  disinfectants! 
was  in  my  nostrils,  and  when  I dined  it  was  the  taste  of  convicts’  food 
I felt  in  my  mouth,  and  that  even  although  the  table  before  me  was- 
exquisitely  set.  Day  and  night  were  the  same  to  me  in  this  respect. 

‘ At  the  end  of  June,  1891,  all  these  phenomena  were  reproduced  in 
an  exasperating  manner,  and  in  August  they  broke  out  again  to  such 
an  extent  that  I entirely  lost  all  feeling.  During  this  period  the  images' 
were  likewise  very  vivid.  In  the  long  sleepless  nights  I seemed  to  see^ 
the  trusted  members  of  the  family  who  were  taking  charge  of  me  changed! 
into  thieves  who  wished  to  rob  me,  and  I rose  to  the  writing-desk,  gob 
the  keys,  and  handed  them  over,  asking  only  that  my  life  should  be' 
spared.  They  were  quite  dismayed,  not  knowing  what  I meant.  On,j 
another  occasion  I saw  their  figures  lengthen,  then  introduce  themselves] 
through  the  keyhole  in  the  room  where  I was,  whilst  I could  distinguish  1 
all  their  features  ; a struggle  then  took  place  between  myself  and  them. ! 
One  night  I had  enacted  before  me  the  scene  of  an  indescribable  outrage 
committed  by  a man  upon  a woman.  The  latter  seemed  to  be  in  bed  | 
in  my  room,  whilst  the  man  was  two  doors  distant.  I perceived  the 
odour  and  even  noticed  the  colour  of  his  sperm  as  it  passed  before  my  I 
nose  in  the  dim  light,  and  I tired  myself  out  in  trying  to  prevent  such  a , 
great  sin,  diverting  the  sperm  with  my  hand. 

‘ As  I have  said  before,  however,  the  most  striking  and  disturbing  I 
phenomenon,  because  of  the  consequences  it  had  for  me,  was  that  of  the  j 
echoes.  These  reflected  all  that  I thought,  all  that  I heard,  all  that  i 
was  repeated  around  me,  whether  at  hand  or  at  a distance,  just  within  i 
reach  of  my  hearing,  which  was  morbidlv  acute  and  sensitive.  Once  ^ 


they  were  formed,  it  was  not  in  my  power  to  restrain  o'  regulate  them;  li 
they  had  to  be  exactly  repeated,  and  I was  entirely  passive.  The  striking  u 


SENSORY  INSANITY 


709 


fact  was  that  the  insistent  repetitions  were  always  in  direct  ratio  to  the 
impression  which  they  produced  in  my  mind. 

‘ I as'ert  with  perfect  certainty  that  I heard  noises  of  every  kind, 
but  especially  the  voices  of  others,  who,  assuming  my  voice,  made  known 
to  others  my  echoes,  which  were  repeated  without  my  knowledge  ; and 
if  two  were  speaking  near  me  their  voices  struck  on  my  tympanum  as 
the  reproductions  of  my  voice,  hence  the  ill-regulated  thoughts  that  were 
aroused  in  mv  mind. 

‘ The  baneful  effect  of  the  echoes  varies  also  according  to  the  voices 
that  give  rise  to  them.  It  is  least  if  the  voice  which  provokes  them^  is 
harmonious  and  pleasantly  modulated  ; it  is  more  marked  if  the  voice 
is  loud  and  more  or  less  harsh  ; it  is  very  marked  if  the  voice  is  dis- 
cordant, loud,  and  sonorous  ; it  is  even  greater  if  it  is  sonorous  and 
caden-ed ; it  is  really  terrible  if  it  is  cadenced  and  vibrating. 

‘ After  my  previous  experience  of  such  echoes  I fought  against  them 
in  the  beginning  of  the  second  stage  of  the  disease,  and  restrained  them 
as  much  as  I was  able  ; but  when  I was  unsuccessful,  as  was  most  usually 
the  case,  I used  to  mix  up,  interpose,  and  transpose  names  and  things, 
thus  rendering  them  as  little  intelligible  as  possible,  and  after  great  efforts 
I began  to  obtain  a moderate  result.’ 

After  a long  harangue  upon  the  effects  of  hypnotism,  he  thus  con- 
cludes : ‘ The  phenomena  are  always  the  same,  but  always  more  govern- 
able, less  insistent,  less  remarkable.  What  will  be  the  principal  phases  ? 
How  long  will  they  last  ? The  future  will  reveal.’ 

He  is  afflicted  by  visual  as  well  as  by  auditory  hallucinations.  He 
is  present  at  a continual  succession  of  confused  scenes,  like  phantasma- 
goriis — plants,  objects,  men,  places,  etc. — which  are  a true  torment  to 
him  although  he  is  conscious  they  are  due  to  errors  of  the  senses. 

Sometimes  he  is  seen  to  move  his  lips  very  slightly,  as  if  he  were 
speaking  in  an  undertone  with  someone,  and  often  he  stops  the  discourse 
abruptly,  resuming  it  if  called  upon  by  his  interlocutor.  This  pheno- 
menon gives  ground  for  believing  that  the  echoes  of  which  we  have  spoken 
are  complicated  by  motor  verbal  hallucinations. 

Here  is  another  case  like  the  preceding,  affording  a slight  indica- 
tion as  to  the  mode  of  development  of  deliria  : 

Observation  XXVII. — C.  Italia,  thirty-nine  years  of  age,  was 
, admitted  into  the  clinique  on  December  15,  1903.  Her  mother  was 
hysterical.  Patient  was  married  against  her  will  to  a man  whom  she  did 
not  like  ; she  lived  some  years  with  her  husband  in  little  else  than  the 
worst  possible  manner,  without  harmony  of  minds  and  interests  having 
been  established,  and  when,  six  or  seven  years  ago,  she  made  up  her 
mind  to  return  to  her  mother’s  house,  she  brought  back  no  other 
remembrances  of  her  married  life  than  those  of  the  carnal  brutality  of 
her  husband,  and  of  the  great  disgust  that  his  embraces  produced  in  her. 
Ultimately  she  gave  herself  up  to  spiritualism,  in  regard  to  which  she  read 
many  books,  and  carried  out  many  experiments.  For  a certain  time  she 
firmly  believed  in  the  existence  of  spirits,  which  answered  to  her  invoca- 
tions, obeyed  her  commands,  peopled  with  spectres  the  room  where  she 
passed  days  and  sleepless  nights,  and  tormented  her  ears,  near  to  which 
^ they  passed,  with  their  shrieking  and  hissing.  Now,  however,  she  has 
changed  her  opinion.  ‘ All  our  visions,’  she  affirms,  ‘ are  the  products 
' of  our  thoughts  ; they  are  even  products  that  our  thought  repels.  When 
I see  a person,’  says  the  patient,  who  is  fairly  well  cultured,  ‘ I impress 
his  image  on  my  mind,  and  am  able  to  reproduce  it  clearly  at  will.’ 

After  giving  subtle  explanation  of  the  hallucinatory  facts,  she  writes 
I in  regard  to  thought  : 


710 


PSYCHIATRY 


‘ Human  thought  does  everything.  All  the  worlds  which  occupy 
space  are  only  the  condensation  of  human  thought,  and  so  many  images  ‘ 
which,  issuing  from  the  brain  of  many  men,  blend  together  and  condense 
forming  worlds.  Thought,  which  manifests  itself  outwardly  in  all  its 
forms,  from  the  most  elementary  and  simple  to  the  highest  and  most 
complex,  is  not  something  evanescent,  ethereal,  impalpable  ; it  has 
instead,  an  essence  which  can  make  itself  tangible  by  condensation,  an 
essence  which  can  be  materialized  to  the  point  of  forming  the  stars  • 
all  the  more  admissible  is  it  that  it  may  create  spirits.’ 

^ Sometimes  I have  felt,  and  feel  often  yet,  as  if  a gust  of  wind  were 
])assing  close  to  me  and  shrieking  in  my  ear  : • • I am  a thought  launched 
by  someone  into  space.”  ’ 

Given  this  materialization  of  human  thought,  and  the  tangible  forms 
that  it  assumes  outside  of  us,  she  is  no  longer  astonished  by  the  fact  that 
her  thought  may  be  read  by  all,  and  that  it  may  be  repeated  outside  of  I 
her  as  soon  as  it  is  outlined  in  her  brain.  The  most  fleeting,  the  least 
meditated  of  her  thoughts,  at  the  very  moment  of  its  formation,  becomes  i 
repeated  in  her  ear  by  other  persons  whom  she  does  not  know.  They  j 
are  not  words  which  she  feels  in  her  brain,  in  her  cranium  ; she  hears  ; 
them  pronounced  in  her  ear,  and  they  come  from  without  : she  cannot  ! 
be  mistaken  as  to  that — the  perception  is  precise.  Succession  of  the  j 
two  phenomena— formation  of  the  thought  in  her  mind  and  the  repetition  ' 
m her  ear -is  wanting.  Such  is  their  simultaneity  that  she  is  almost 
irritated  that  others  outside  of  her  should  find  instantaneously  the  verbal 
form  of  her  thought  before  she  finds  it  herself.  It  is  a phenomenon  that 
used  to  madden  her  before  she  became  aware  of  the  explanation  of  it. 
Sometimes,  simultaneously  with  the  hearing  of  the  word  in  her  ear, 
she  observes  a certain  movement  in  her  tongue,  as  if  it  were  putting 
itself  into  position  for  pronouncing  the  same  word.  j 

She  often  feels  also  sharp  prickings  on  the  hairy  and  other  parts  of  '! 
her  body,  but  by  preference  on  the  head  : they  are  the  thoughts  of 
others,  which  sometimes  reach  her  with  violent  rapidity,  and  in  penetrating 
to  her  brain  they  cause  her  pain.  Once  she  had  the  impression  that  an  j 
entire  head  had  entered  her  own,  tearing  the  cerebral  coverings.  It  was  j 
not  a false  impression  : her  head,  her  old  head,  was  substituted  at  that  ' 
moment  by  a new  head.  On  another  occasion  she  felt  as  if  a strong 
wind  had  penetrated  the  vulva  and  gone  out  by  her  mouth,  passing 
through  her  and  almost  tearing  in  pieces  the  abdominal  and  thoracic  t 
viscera.  It  was  certainly  a thought,  a strong  thought,  of  unknown  * 
origin,  which  crossed  and  shook  her  organism.  The  phenomenon  was  ' 
not  repeated.  *[ 

The  patient  has  also  formed  her  opinion  as  to  the  capacity  of  human 
thought  to  clothe  itself  in  an  outward  form,  creating  spirits  and  worlds,  ‘ 
and  whether  all  human  beings  possess  this  capacity  equally,  or  whether 
there  ai  e privileged  beings  who  enjoy  it  or  suffer  from  it  in  larger  measure. 
She  believes  that  while  it  is  a possession  common  to  all  men,  being  even 
potent  in  all,  it  is  in  a certain  way  more  developed,  more  actual,  in  women 
who  do  not  bear  children. 

In  this  sufferer  the  fact  has  to  be  noticed  that  while  she  feels  herself 
unhappy  and  uneasy  in  every  situation,  she  does  not  at  the  actual 
moment  blame  any  living  being  for  her  misadventures.  Her  brother, 
niothei,  and  husband  are  responsible  mediums  m the  sense  that  by  certain 
acts  which  she  imputes  to  them  they  have  produced  such  modifications 
in  hei  organism  that  her  life  has  been  developed  diffe  ently  from  that  i 
oi  otheis.  Now,  however,  she  is  a victim  to  cosmic  forces,  from  the  ' 
dominion  ot  which  no  one  can  release  her.  Probably  her  brother,  mother, 
and  husband  did  not  know  the  tragic  consequences  of  apparently  simple 


SENSORY  INSANITY 


711 

Another  point  in  her  history,  which  we  gathered  from  conversation 
with  her,  and  which  we  have  not  had  an  opportunity  of  confirming 
is  that  in  the  period  when  she  gave  herself  up  to  spiritualism  she  had 
longer  or  shorter  phases  of  complete  unconsciousness  of  which  she  has 
no  remembrance  (duplication  of  the  personality  ?). 

In  this  case  we  cannot  speak  of  paranoia.  If,  nevertheless, 
there  is  some  slight  paranoic  manifestation,  the  whole  scheme  of 
the  disease  is  formed  by  the  action  of  the  hallucinations  to  which  the 
sufferer,  who  is  intelligent  and  cultivated,  gives  an  interpretation,- 
the  elements  for  which  she  draws  from  her  spiritual  culture.  Her 
personality,  meanwhile,  is  neither  altered  in  a paranoic  sense  nor 
disintegrated. 

The^re  is,  then,  one  form  of  sensory  insanity  which  does  not 
produce  remarkable  changes  of  the  psychic  personality,  neither  con- 
fusion, melancholia,  nor  deliria,  and  which  is  maintained  for  a period 
of  time  of  greater  or  less  length,  save  for  brief  episodes  of  one  of 
these  phenomena.  Moreover,  it  is  a form  which  cannot  be  con- 
fused with  any  other  of  the  sub-groups  of  sensory  insanity  that  we 
are  going  to  describe. 

We  come  now  to  the  third  sub-group  of  sensory  insanity,  in 
regard  to  which  a rich  literature  exists,  since  it  includes  also  mental 
confusion,  on  which,  especially  during  these  later  years,  very  intei- 
esting  works  have  been  published  ; but  notwithstanding  these,  it 
cannot  yet  be  asserted  that  the  subject  is  exhausted. 

I refer  to  that  form  of  sensory  insanity  which  is  manifested  by 
acute  or  sub-acute  phenomena,  or  which  develops  insidiously,  and 
gives  as  a constant  result  confusion,  stupor,  or  stupidity  of  different 
degree,  which,  once  established,  becomes  the  most  important  feature 
of  the  whole  morbid  picture.  It  is  the  so-called  ‘ acute  dementia, 
which  includes  ‘ acute  sensory  delirium  ’ (Schiile,  Krafft-Ebing),  the 
Verwirrtheit  and  the  V erwovrenheit  of  the  Germans  (Ziehen,  Fiitsch, 
Wille,  Konrad,  and  others),  besides  the  amentia  of  Meynert,  the 
stupidity  and  mental  confusion  of  the  French  (Dagonet,  Chasliii), 
and  the  majority  of  the  cases  of  dementia  prsecox  of  Kraepelin. 

The  confusing  terminology  of  this  disease  depends  on  the  veiy 
varied  forms  which  it  assumes,  and  on  the  persistency  of  certain 
symptoms  which  impress  quite  a particular  physiognomy  on  syn- 
dromes that  have  been  mistaken  for  distinct  diseases.  Add  to  that 
the  long  duration  of  the  disease,  making  it  difficult  to  lay  hold  of 
it  at  its  very  commencement.  In  the  construction  of  the  morbid 
figures  the  individual  factor  has  evidently  been  neglected.  If,  in 
consequence  of  hallucinations,  one  personality  is  not  disintegrated, 
whilst  a second  becomes  paranoic  (becomes  transformed,  but  pre- 
serves a logical  capacity  in  the  delirious  manifestations),  and  a third 
is  decomposed  or  dissociated  (confusion,  amentia,  acute  dementia), 
and  manifests  itself  under  a great  variety  of  forms,  now  by  psycho- 
motor excitement,  then  by  stupor,  by  melancholic  or  joyful  char- 


712 


PSYCHIATRY 


acters  (melancholic  variety  and  maniacal  variety),  by  catalepsy 
and  paranoid  formations,  etc.,  still  it  is  not  to  be  held,  because  of 
all  these  varieties,  that  they  are  different  diseases.  They  are  one 
disease.  It  begins  with  hallucinations  or  illusions  ; these  have  a 
disintegrating  power  over  the  personality,  whose  attitudes,  once 
decomposed,  are  m*ost  diverse,  owing  to  intrinsic  reasons  and  the 
intensity  of  the  primary  cause. 

No  sure  distinction  can  be  made  between  the  acute  and  the 
chronic  form  of  hallucinatory  confusional  insanity,  because,  if  it 
is  true  that  in  some  cases  the  disease  runs  an  acute  course  for  weeks 
or  months,  in  others  the  acute  phase  is  very  short,  and  gives  place 
to  syndromes  which  in  no  way  differ  from  the  acute  forms  or  from 
those  which  are  not  preceded  by  an  acute  hallucinatory  phase. 

To  tell  the  truth,  it  is  generally  agreed  that  hallucinations  are 
almost  always  present  in  the  morbid  picture  ; but  whilst,  owing 
to  certain  varieties  of  mental  confusion,  some — as,  for  example, 
]\Ieynert,  Schule,  Krafft-Ebing,  Fiirstner,  Serbsky,  Ventra,  Del 
Greco,  Lutzenberger,  Noera,  and  many  others — give  to  them  the 
value  of  an  essential  symptom,  especially  in  the  case  of  that  acute 
form  of  sensory  insanity  called  acute  sensory  delirium,  delirium 
of  inanition  (Brequet),  acute  hallucinatory  paranoia  (Westphal), 
others  hold  the  hallucinations  to  be  a secondary  and  not  essential 
symptom  of  the  disease.  Amongst  these  we  have  to  mention 
Fritsch,  Clouston,  Chaslin,  Seglas,  Kraepelin,  and  Morselli. 

Several  authors  distinguish  clearly  two  forms  of  confusion — the 
hallucinatory  and  the  primary.  Amongst  these  is  Kraepelin. 

Clinical  observation,  however,  shows  that  acute  sensory  delirium, 
or  acute  hallucinatory  dementia,  is  only  a variety  of  sensory  insanity, 
in  which  should  be  included  many  other  morbid  states  characterized 
by  hallucinations  which,  with  or  without  an  acute  explosion  pre- 
ceding, primarily  or  insidiously  produce  mental  confusion  or 
stupidity,  which  very  often  presents,  especiall}^  in  the  adolescent 
and  the  young,  the  signs  of  dementia  praecox  and  its  varieties — 
katatonia  and  sensory  paranoia. 

These  three  syndromes  cannot  be  distinguished  from  acute 
mental  confusion,  acute  dementia,  or  amentia  ; neither  are  they  well 
distinguished  from  one  another,  but  run  into  one  another  in  such  a 
manner  that  the  dement  of  this  group  (dementia  praecox)  is  sometimes 
katatonic  and  paranoid,  whilst  the  paranoid  subject  almost  always 
suffers  from  dementia  praecox,  and  may  present  katatonic  phases. 
All  three  may  proceed  from  acute  sensory  delirium  (Verwirrtheit), 
or  may  develop  slowly.  An  interesting  point  in  the  pathology  and 
interpretation  of  these  syndromes  is  that  in  the  majority  of  the  cases 
we  find  preceding  an  acute  or  sub-acute  hallucinatory  period,  or 
single  hallucinations  which  disintegrate  and  dissociate,  rapidly  or 
gradually,  the  components  of  the  psychic  personalit}^  and  give  rise 
to  the  more  classic  amentia,  or  to  more  or  less  strange  aggregations 


SENSORY  INSANITY 


713 


composed  of  the  fragments  of  the  personality  mixed  with  and 
animated  by  the  hallucinatory  products  which  tend  to  fix  and  give 
a particular  physiognomy  to  these  new  products  (paranoid). 

Clinical  observation  does  not  permit  the  distinction  of  acute 
dementia  from  simple  confusion,  because  both  represent  forms  and 
degrees  of  the  same  disease,  and  stupor,  confusion,  excitement,  and 
lucidity  often  alternate  in  the  same  individual.  A superficial 
review  of  the  clinical  cases  would  also  demonstrate  to  any  observer 
that  the  hallucinatory  phase  of  long  or  short  duration  is  followed 
now  by  stupor,  now  by  confusion,  with  or  without  katatonia,  and 
that  the  distinction  maintained  by  several  authors,  and  amongst 
the  latest  by  Connolly  Norman,  has  no  objective  foundation. 

From  this  group  are  excluded  primary  confusion  or  stupidity 
(very  rare)  on  the  one  hand,  and  on  the  other  acute  paranoia, 
which  is  a disease  clearly  distinguished  from  confusional  hallucina- 
tory insanity  by  its  clinical  form  and  the  psycho-pathological 
mechanism  of  the  phenomena  it  presents. 

From  a semeiological  point  of  view,  we  may  thoroughly  agree 
with  the  opinion  expressed  by  Scliule,  Orchanscky,  Kirchhoff, 
Ziehen,  that,  no  m.atter  what  form  mental  confusion  may  assume, 
there  are  three  symptoms  which  are  almost  never  wanting — viz., 
incoherence,  hallucinations,  and  deliria.  Careful  observation,  how- 
ever, has  shown,  and  the  future  will  still  more  clearly  reveal,  that 
the  incoherence  and  delirium  are  produced  by  the  hallucinations, 
and  that  in  its  tout  ensemble  this  affection  should  be  regarded  as 
a disease  of  the  sensory  sphere. 

The  following  succinct  observations  will  convey  a better  notion 
of  the  affection  than  any  formal  description  • 


Observation  XXVIII. — Sch.  C.  di  P.,  aged  twenty-three,  single  in 
comfort  able  circumstances,  well  educated,  Roman  Catholic,  was  admitted  to 
the  Clinique  at  Naples,  April  20, 1901.  A maternal  aunt  was  insane.  Of  a 
mild  disposition  but  very  impressionable,  she  readily  abandoned  herself 
to  fantastic  conceptions,  neglecting  her  household  duties.  Not  very 
capable  of  appreciating  the  real  value  and  practical  aspect  of  things, 
she  displayed  in  all  her  actions  a certain  degree  of  originality,  and  at 
times  did  strange  things  that  called  forth  rebukes,  which  she  took  too 
much  to  heart. 

About  twenty-eight  days  before  admission  true  mental  disturbances 
were  initiated  with  hallucinations  of  sight  and  hearing.  Whilst  beside 
her  father  she  all  at  once  threw  her  arms  round  his  neck,  and  in  an  agony 
of  fear  pointed  to  a spot  where  she  beheld  a vision  of  her  lover,  at  the 
same  time  calling  : ‘ Hold  him,  hold  him  ! he  is  ripping  himself  open.’ 

She  remained  for  some  time  as  though  terror-stricken,  trembling, 
sometimes  apparently  self-absorbed,  and  made  no  response  to  the  anxious 
inquiries  of  her  father.  She  then  regained  consciousness  temporarily, 
embraced  her  father,  and  wept.  Soon  new  and  more  varied  auditory 
and  visual  hallucinations  appeared.  Most  of  them  were  of  a terrifying 
nature,  having  reference  to  her  enemies,  her  lover,  his  assailants  or 
murderers  ; again  it  was  threatening  and  mysterious  voices,  revolver 
shots,  unusual  noises  in  the  house,  and  under  her  bed.  These  were 


7^4 


PSYCHIATRY 


followed  by  an  intense  motor  agitation,  with  confusion,  logorrhoea,  inco- 
herence, impulses,  and  attempts  to  throw  herself  from  the  balcony. 

These  phases  alternated  with  others  of  comparative  calm  and  with 
dreamy  states.  Her  speech,  however,  always  had  reference  to  the 
content  of  the  hallucinations.  In  this  condition  she  was  brought  to  the 
asylum. 

On  admission  she  was  in  a state  of  stupor  ; when  questioned  she  made 
no  reply,  then  all  at  once  she  exclaimed  : ‘ Give  me  a blow  on  the 
forehead  so  that  I may  be  done  with  it  all.’ 

After  admission,  phases  of  intense  agitation  alternated  with  phases 
of  exhaustion  and  of  brooding.  She  refused  and  resisted  all  attempts  to 
arouse  her  interest.  She  had  always  a dim  consciousness  of  what  was 
happening  around  her.  Her  perceptions  of  the  external  world  were 
very  vague,  and  each  of  them  acquired  a fanciful  character,  or  became 
elaborated  by  her  delirious  fancy.  According  as  one  or  another  stimulus 


Figs.  92  and  93. — Hallucinatory  Confusional  Insanity  (Acute 

Dementia). 


acted  upon  her  the  expression  of  her  countenance  changed  from  moment 
to  moment.  If  anyone  accosted  her,  if  she  heard  any  noise,  if  she  noticed 
any  movement  whatsoever  near  her,  she  first  looked  round  with  curiosity, 
then  turned  away  quite  frightened  with  an  expression  of  great  terror. 
The  following  is  a resume  of  her  clinical  history  : She  hides  herself  under 
the  bedclothes,  is  agitated,  shouts  out,  curses,  calls  for  help,  and  then 
pp'haps  suddenly  smiles.  Her  psychic  personality  is  broken  up  and 
disconnected ; she  lives  amidst  a continuous  whirl  of  false  perceptions 
and  fragmentary  recollections,  and  particularly  in  a web  of  illusions 
and  hallucinations  usually  of  a terrifying  nature.  She  often  raises  her 
head  Irom  the  jiillow,  fixes  her  gaze  on  some  particular  spot,  or  looks 
under  her  bed,  then  calls  out  : ‘ Murder  ! thieves  ! go  away  ! Will  you 
he  quiet?  1 know  nothing!  For  charity's  sake  kill  that  infamous  wretch 
who  wishes  to  dishonour  me  ! Don't  you  see  him  ?.  Drive  him  away  I 
Don't  you  hear  how  he  knocks  under  my  bed  ?'  Then  she  falls  back  on  the 
bed  wearied,  discouraged,  dazed,  and  murmurs  some  words  whose 


SENSORY  INSANITY 


715 


meaning  it  is  impossible  to  decipher,  as  they  are  ahvays  incoherent.  At 
other  times  erotic  images  seem  to  run  riot  in  her  mind,  and  she  abandons 
herself  to  them  voluptuously.  For  example,  she  is  heard  to  say  : ‘ Come, 
don't  run  away  from  me ; don't  stand  always  011  the  ^ame  spot !'  Very  soon, 
however,  these  same  images  arouse  in  her  a gradually  increasing  terror, 
and  she  calls  out  and  tries  as  usual  to  free  herself,  to  make  her  escape. 
She  exhibits  marked  reflex  excitability  and  hyperaesthesia  m all  the 
psvcho-sensory  spheres.  If,  while  she  is  in  a state  of  calm  or  in  a drowsy 
condition,  or,  as  may  be  interpreted  from  her  physiognomy,  indulging 
in  dreams  of  pleasurable  content,  we  make  a noise  or  touch  her,  soon 
there  presents  itself  the  state  of  psycho  motor  agitation  : she  contorts 
herself;  her  limbs  and  1runk  become  rigid,  her  countenance  anxious, 
and  the  terrifying  hallucinations  are  reproduced.  After  a little  she 
laughs,  weeps,  and  threatens  to  fall  again  into  her  wonted  state  of 
anguish.  She  refuses  everything  (negativism). 

Her  physiognomy  is  mobile  and  troubled:  at  one  moment  she  is 
smiling,  the  next  frowning  ; now  she  is  indifferent,  now  threatening, 
now  listless  ; her  eyes  are  restless  and  at  the  same  time  without  expres- 
sion. She  does  not  fix  them  on  any  person  or  thing  except  in  a fleeting 
and  distracted  manner.  Objects  and  persons  pass  in  front  of  her  as  before 
one  asleep.  Everything  she  sees  and  fails  to  perceive,  or  perceives 
imperfectly,  provokes  immediate  incoherent  reactions.  To  one  she 
addresses  an  insulting  or  meaningless  word  or  phrase,  mistaking  that 
person  for  someone  else  ; another  she  threatens  in  a brazen  and  absurd 
manner,  and  then  smiles  as  if  she  beheld  some  pleasant  phantasrn.  The 
words  she  pronounces  are  always  a fragmentary  record  of  past  images, 
or  the  half  of  a phrase  repeated  on  former  occasions.  She  touches, 
tears,  gesticulates,  and  rushes  about.  She  has  been  spitting  continuously 
for  several  months ; this  is  a residual  tic  from  a true  salivation  that  was 
present  in  the  acute  period  of  the  illness. 

The  following  case,  selected  from  amongst  many,  is  very  different 
in  form,  but  identical  in  substance  : 

Observation  XXIX.— T.  L.  Giuseppe,  aged  twenty-one,  single, 
rustic,  in  humble  circumstances.  At  his  birth  his  mother  was  thirty-four, 
his  father  fifty-four  years  of  age,  the  latter,  even  at  that  age,  healthy 
and  free  from  vice.  There  is  no  history  of  delinquency,  drunkenness,  o 
anything  unusual  in  the  family.  The  patient  has  always  been  honest, 
industrious,  and  without  evil  tendencies.  Neither  vice  nor  grave  disease 
figures  in  his  personal  history.  About  the  middle  of  January  he  had  an 
attack  of  influenza.  On  the  third  night  after  the  fever  had  left  him, 
and  all  around  was  quiet,  he  arose  in  consternation,  saying  that  he  had 
seen  the  Madonna,  who  announced  to  him  his  imminent  death.  He 
remained  trembling,  his  eyes  gazing  into  space,  momentarily  expecting 
the  Madonna  to  announce  to  him  his  last  hour.  This  excited  and 
emotional  state  continued  almost  unabated  till  the  morning,  and  at 
daybreak  he  succeeded  in  escaping  through  the  window,  whence  he  made 
his  way  to  a pastry  shop.  Arrived  there,  he  demanded  to  know  where 
he  was  and  who  had  brought  him  ; finally  he  was  taken  home,  but  the 
next  day,  again  eluding  the  vigilance  of  his  friends,  he  shut  himself  up 
in  the  stable,  so  that  it  was  necessary  to  enter  by  a window  to  secure  him. 
Meanwhile  he  refused  his  food,  did  not  sleep,  spoke  very  little,  and  then 
only  of  the  Madonna  and  his  approaching  death,  and  was  a prey  to  terror. 
He  then  began  to  perceive  that  the  water  had  a bad  smell,  on  which 
account  he  would  not  drink  except  from  a water- jug  in  common  use  by 
the  other  members  of  the  family.  His  anxiety  and  fear  increased  to  such 
an  extent  that  the  slightest  noise  struck  terror  to  his  heart  ; he  was 


7i6 


PSYCHIATRY 


continually  repeating  such  words  as  ‘ betrayed,’  ^ death,’  ^ Madonna,’ 
and  on  more  than  one  occasion  made  sudden  attempts  to  injure  himself 
with  his  nails.  Once  he  tried  to  cut  his  throat  with  a piece  of  iron. 

In  this  state  he  was  taken  to  the  asylum. 

At  the  objective  examination  several  anthropological  stigmata  of 
degeneration  were  found. 

All  the  elementary  functions  of  the  nervous  system  were  normal, 
except  for  a slight  inequality  of  the  pupils. 

As  regards  his  mental  condition,  he  exhibited  terror  and  dismay  and 
this  state  was  aggravated  by  the  sight  of  his  parents,  and  by  the  recollec- 
tion of  the  vision  he  had  had,  whereupon  he  was  seized  with  marked 
trembling  and  keen  agitation. 

Meanwhile  his  perceptions  were  sometimes  normal  in  the  sense  that, 
apart  from  the  preoccupations  and  the  slowness,  he  was  capable  of  per- 
ceiving and  judging  rationally  objects,  places,  and  persons.  At  other 
times  he  was  confused  and  dreamy.  Sometimes,  in  replying  to  a question, 
he  would  suddenly  stop  speaking,  almos:  as  though  his  thoughts  had 
flown  elsewhere,  or  as  if  there  were  a defect  in  the  linking  of  one  idea  with 
another,  whereupon  he  would  remain  as  though  stupefied,  so  that  it  was 
necessary  to  repeat  the  question,  to  which  he  would  answer  either  ‘ yes  ’ 
or  ‘ no  ’ as  required. 

Whilst  in  the  ward,  on  the  first  two  days  he  showed  marked  sensory 
disturbances,  as  at  the  commencement  of  his  illness ; he  saw  the 
Madonna  appear  again  at  the  window  facing  his  bed,  and  sometimes 
was  on  the  alert  for  her,  listening  for  her  voice ; and  then  his  delirium 
would  break  out  more  violently  than  before,  his  agitation  and  terror 
become  greater,  since  that  voice  reminded  him  of  the  threat  of  imminent 
death.  During  his  periods  of  calm  he  was  in  a stuporous  state,  inter-  ^ 
rupted  by  fitful  inconclusive  acts,  and  not  infrequently  by  laughter  ^ 
which  scarcely  ever  disturbs  the  rigid  features  of  the  melancholiac.  ' 
Memory  was  only  partially  preserved  ; he  showed  considerable  lapses 
with  regard  to  certain  periods  of  his  illness^  during  which  he  had  done  j 
things  of  which  he  now  retained  no  recollection.  His  associative  capacity  = 
was  weak,  his  speech  incoherent,  both  when  he  spoke  of  his  own  accord — 
a rare  occurrence— and  when  he  replied  to  anything  said  to  him.  His 
ideative  manifestations  gave  indications  of  a rudimentary  form  of 
delirium  of  a depressive  nature,  corresponding  to  his  temperament  and  : 
to  the  recollection  of  the  prophecies  of  his  death.  Ideation  alwavs  i 
centred  around  this  order  of  ideas,  from  the  spell  of  which  he  was  unable  i 
to  free  himself,  and  was  also  so  slow  that  at  times  the  patient  assumed  a 
stupefied  aspect.  ; 

The  consciousness  was  profoundly  disturbed  j d sorientation  was  \ 
evident.  One  day,  for  example,  as  soon  as  he  was  brought  face  to  face  ' 
wdh  his  parents,  who  had  come  to  the  asylum  to  visit  him,  he  was  seized 
with  agitation,  trembling,  praecordial  distress  (illusory  perception),  and, 
without  taking  any  notice  of  their  presence,  turned  to  the  doctor  to  | 
demand  from  him  the  reading  of  his  document  (possibly  he  was  referring 
to  the  sentence  of  death) ; then  he  requested  his  permission  to  go  away,  i 
etc.  Shortly  afterwards,  however,  when  he  found  himself  left  alone  with 
his  parents,  he  conversed  with  them,  and  greeted  them  affectionately. 

The  normal  sentiments  were  all  weakened  or  at  least  reduced  ; only 
occasionally  were  they  momentarily  rearoused,  by  certain  impressions, 
to  be  immediately  substituted  by  others  and  still  others,  with  that  same 
incoherence  and  mobility  that  we  noted  in  his  ideas. 

f already  learned  the  nature  of  his  conduct  at  the  beginning 

ot  his  illness.  At  home  he  showed  violent  impulses  to  do  himself  harm, 
w ith  a tendency  to  break  loose  and  to  flee  unconsciously  from  the  house, 
e c.  , m the  waid  his  conduct  was  somewhat  aimless,  and  betrayed  no 


SENSORY  INSANITY 


717 


desire  except  that,  manifested  from  time  to  time,  of  going  away.  He 
often  spent  the  day  idly  seated  in  a corner,  caring  little  for  company, 
avoiding  conversation  with  his  fellow-patients,  and  on  one  occasion  he 
remained  in  bed  for  two  days,  with  his  eyes  fixed  upon  a window  at  whi:h 
the  Madonna  had  reappeared  to  him.  He  refused  every  invitation,  and 
resisted  all  attempts  to  arouse  him  (negativism).  He  showed  some 
impulses,  some  caprices,  alternating  with  illogical  refusals,  in  which  was 
evident  the  same  incoherence  as  we  noted  in  the  ideas  and  sentiments. 

This  patient  improved  by  degrees.  His  relatives  removed  him  from 
the  asylum  before  he  was  yet  completely  recovered,  but  later  information 
testified  to  his  complete  cure. 

Observation  XXX. — I.  P.,  single,  student  in  the  normal  school. 

According  to  information  supplied  by  her  father,  there  were  no  ante- 
cedent nervous  or  mental  affections  on  either  maternal  or  paternal  side. 
The  patient  appears  to  have  enjoyed  very  good  health  until  the  week 
previous  to  admission,  and  she  had  never  before  given  any  indications 
of  mental  alienation.  She  was  very  studious,  and  bent  on  gaining  her 
certificate  as  mistress.  With  this  object  in  view  she  studied  for  three 
months  night  and  day,  scarcely  sleeping  two  or  three  hours  out  of  the 
twenty-four.  Notwithstanding  this  hard  work,  when  she  presented 
herself  for  the  quarterly  examination,  she  was  unsuccessful.  She  was 
greatly  upset  in  consequence,  and  wept  copiously.  A few  days  after- 
wards she  commenced  to  be  agitated,  did  not  recognise  the  members  of 
her  family,  and  in  her  delirium,  as  it  was  called  by  those  in  the  house, 
she  was  continually  repeating  things  learned  at  school,  but  in  an 
incoherent  manner. 

She  was  admitted  to  the  ward  in  this  state  on  January  13, 

1893- 

On  January  14  and  15  she  showed  marked  agitation  with  vivid 
hallucinations.  There  was  a continual  flight  of  ideas  and  words  bearing 
no  connection  with  one  another,  or  often  merely  that  of  assonance.  Her 
face  was  pale,  her  eyes  bright ; she  tossed  about  continually,  so  that  it  was 
necessary  to  restrain  her  movements.  Her  attitude  and  physiognomy 
changed  every  moment  ; most  frequent  y they  were  significant  of  anguish 
and  terror,  but  she  often  seemed  to  hear  voices  and  to  see  persons,  at  one 
moment  conversing  amiably  with  them,  the  next  railing  against  them, 
or  beseeching  them,  etc.  She  made  no  replies  to  questions,  and  to 
stronger  stimuli  she  reacted  in  a fleeting  manner  ; now  and  again  she 
exhibited  verbigeration,  and  fell  into  a semi-stuporous  state,  only  to 
recommence  later  her  former  behaviour.  She  refused  all  food  except 
milk  ; for  two  nights  her  insomnia  was  not  successfully  combated  by 
the  hypnotics  administered.  On  the  third  day  a state  of  calm  began 
to  manifest  itself,  and  with  it  her  consciousness  became  partially  clear  ; 
she  remembered  some  things  which  had  happened  to  her  during  the 
preceding  days,  and  was  to  a certain  extent  conscious  of  her  condition  ; 
she  recognised  that  she  was  in  an  asylum,  and  said  : ‘ It  is  undoubtedly 
the  strange  actions,  the  cries,  and  senseless  words  of  the  other  patients 
that  has  gi  en  me  the  idea  that  this  is  an  asylum  I have  been  broug  it  here 
without  good  reason,  for  I am  no  imbecile.’  She  expressed  a desire  to 
return  home,  asked  for  her  brother,  whose  voice  she  declared  she  had 
heard  repeatedly,  and  was  surprised  to  hear  that  none  of  her  brothers 
had  been  to  the  asylum  to  visit  her. 

She  felt  very  weak,  as  though  she  had  awakened  from  a sleep  disturbed 
by  disquieting  dreams,  and  had  no  appetite.  There  were  also  great 
blanks  in  her  memory  ; she  had  forgotten  a great  deal.  Many  recollec- 
tions were  simply  fragmentary ; sometimes  they  were  a confused  mixture 
of  actual  facts  and  hallucinatory  products,  although  she  gave  a lairly 


7i8 


PSYCHIATRY 


accurate  account  of  her  previous  history,  stating  that  at  her  examinations 
she  desired  to  display  the  full  extent  of  her  knowledge,  that  this  gave 
rise  to  the  confusion,  and  she  was  ashamed  she  did  not  possess  the 
requisite  stock  of  knowledge  for  a successful  result.  She  inquired  with 
interest  as  to  the  health  of  her  parents,  and  in  temperament  showed 
herself  dull,  melancholic,  and  desirous  of  solitude. 

This  phase  of  improvement  was  of  short  duration,  and  confusion 
became  gradually  more  marked ; her  recollections  became  less  clear 
and  precise,  the  blanks  in  memory  wider  and  deeper,  the  ideative  process 
slower  and  more  disconnected,  the  demeanour  more  varied.  Indiffer- 
ence towards  he-  family  and  her  own  interests  became  greater,  inco- 
herence in  speech  and  in  action  more  pronounced.  She  ate  her  food 
in  a slovenly  fashion,  often  soiled  her  clothing,  and  lost  weight  every 
day.  She  did  nothing  she  was  asked  to  do,  and,  in  fact,  often  reacted 
with  violence.  She  was  very  often  detected  addressing  herself  to  a 
corner  of  the  room  or  to  the  top  of  the  window,  and  assuming  a listening 
attitude  (hallucinations).  She  gave  way  to  more  or  less  impulsive  and 
meaningless  actions,  and  her  physiognomy  became  more  blank  and 
expressionless. 

In  the  month  of  March  she  showed  some  improvement.  The  hallu- 
cinations became  less  vivid  and  frequent ; she  was  capable  of  adapting 
herself  to  some  employment  in  our  workrooms  ; she  commenced  to  take 
care  of  her  personal  appearance,  and,  although  spontaneous  ideation  was 
almost  nil,  or  merely  the  expression  of  the  products  of  her  sensory  dis- 
orders, yet  there  was  noticed  a certain  reawakening  of  attention  to  inter- 
rogations, to  which  she  sometimes  replied  in  a sufficiently  coherent  . 
manner. 

In  July  she  had  almost  completely  recovered.  Hallucinations  had  ", 
become  less  frequent  and  less  vivid,  and  thought  at  the  same  time  ' 
stronger  and  more  ordered.  Her  consciousness  became  gradually  ' 
restored,  and  she  retained  the  memory  of  this  long  period,  whereof 
she  recollected  particularly  the  most  vivid  hallucinations,  estimating  \ 
their  pathological  value  fairly  well.  No  trace  was  left  of  delirious  = 
ideas.  The  ideative  field  was  certainly  restricted,  but  the  power  of 
reproducing  and  associating  the  images  in  a certain  sphere  was  restored, 
and  at  the  same  time  the  affective  sentiments  and  those  of  honesty, 
decorum,  and  propriety  revived.  For  example,  during  her  illness  she  ’ 
went  most  often  barefooted,  her  hair  loose,  her  clothes  unbuttoned,  her  ( 
hands  and  face  dirty,  except  when  they  had  just  been  cleaned  for  her.  | 
Later  on  she  took  care  of  her  personal  appearance  like  any  other  respect-  ( 
able  person.  There  remained  behind  a slight  tinge  of  melancholia,  of  *■ 
which  she  found  the  explanation  in  the  trouble  she  had  passed  through,  j 
and  in  the  long  abandonment  of  her  favourite  studies.  She  was  dis- 
charged recovered  on  July  12,  1894. 

In  some  instances  the  malady  runs  a very  short  course,  the 
acute  hallucinatory  phase  being  followed  by  a rapid  recovery 
instead  of  chronic  amentia.  The  following  is  an  example  : 

Observation  XXXI. — Fel.  Ant.,  from  Casalnuovo,  aged  twenty-two, 
single,  joiner,  was  admitted  into  the  asylum  on  December  19,  1903. 

Hereditary  history  was  negative.  Towards  the  middle  of  September 
the  patient  fell  ill  with  an  infective  fever,  which  lasted  two  months. 
On  recover}^  he  returned  to  his  work,  but  after  a few  days  (about  Decem- 
bei  10)  he  showed  general  debility,  slight  bronchial  signs,  high  tempera- 
ture (40°  C.  for  three  days).  During  this  period  he  had  vivid  hallucina- 
tions, was  greatly  agitated,  and  committed  a number  of  strange  actions, 
which  ended  in  his  removal  to  the  asylum. 


719 


SENSORY  INSANITY 

For  the  first  four  days  after  admission  he  was  very  excited,  had 
hallucinations  with  hostile  content  (certain  persons  belonging  to  his 
district  wished  to  heap  abuses  upon  him,  and  laid  traps  for  him  in  a 
thousand  ways),  and  was  so  confused  that  he  had  not  the  slightest  notion 
of  the  nature  of  his  new  environment.  He  was  continually  addressing 
imaginary  persons,  was  unsettled,  sought  to  escape  from  his  bed,  used 
abusive  language,  or  was  timorous  and  dejected. 

After  appropriate  treatment  by  purgatives,  intestinal  disinfectants, 
hypodermic  transfusions,  the  patient  soon  improved.  After  only  two 
weeks  he  began  to  take  notice  of  the  place  and  the  persons  surrounding 
him,  remembered  in  a confused  way  the  events  that  had  led  to  his 
removal  to  the  asylum,  and  showed  a keen  desire  to  return  to  his  family 
and  to  resume  his  work.  He  was  discharged  recovered  one  month  from 
the  date  of  admission. 

In  other  instances,  however,  a single  hallucination,  if  intense, 
produces  an  apparently  melancholic  condition,  which  gradually  takes 
on  all  the  features  of  the  stupidity  described  by  the  French  authors, 
and  of  acute  dementia. 

In  the  second  part  of  this  treatise  (p.  21 1)  I have  reported  the 
case  of  a man  who,  as  the  result  of  a hallucination,  cut  off  his  hand. 
That  man  remained  confined  in  the  asylum  with  the  most  pro- 
nounced form  of  dementia  prmcox. 

As  a rule,  we  have  to  deal  with  strongly  predisposed  individuals, 
in  whom  the  hallucination  acts  like  a severe  physical  or  moral 
injury  to  the  brain.  The  stupor  or  the  acute  dementia  is  pro- 
longed indefinitely,  without  any  necessary  repetition  of  the 
hallucination. 

vSuch  cases  might  readily  be  multiplied,  as  these  varieties  of 
sensory  insanity  are  the  most  frequent  of  all. 

What  strikes  the  observer  at  once  in  patients  cf  this  category 
is  the  constant  association  of  the  hallucinations  with  the  mental 
confusion,  which  is  more  or  less  prompt  and  intense,  according  to 
the  vividness  and  number  of  the  hallucinations,  as  well  as  the 
cohesion  of  the  constituent  elements  of  the  psychic  personality  of 
the  individual  patients. 

The  want  of  agreement  amongst  the  different  authorities,  which 
has  given  rise  to  a large  number  of  synonyms  foi  the  affection  with 
which  we  are  dealing,  is  undoubtedly  due  to  the  fact  that  the  majority 
of  the  patients  come  under  observation  days  or  weeks  after  the 
initiation  of  the  disease,  just  when  the  hallucinations  have  become 
less  vivid  and  less  frequent,  and  confusion  reigns  in  their  stead. 
The  truth  is  that,  whilst  there  are  cases  in  which  it  is  impossible 
to  be  certain  cf  the  existence  of  hallucinations,  by  far  the  most 
common  cases  are  those  in  which  the  hallucinations  initiate  and 
furnish  most  of  the  colouring  to  the  clinical  picture,  then  become 
less  frequent  and  more  fleeting.  It  is  only  when  we  are  in  the 
happy  position  of  having  a large  practice  outside  the  asylum,  and 
especially  when  there  is  an  outdoor  department  in  connection  with 
the  Clinique,  such  as  we  have  organized  in  Naples,  that  we  are 


720 


PSYCHIATRY 


enabled  to  catch  the  disease  at  its  very  commencement,  and  to 
follow  its  course  until  it  reaches  such  a degree  of  development  as  i 
calls  for  the  removal  of  the  patient  to  the  asylum.  We  may  affirm 
that,  if  not  in  all,  at  least  in  the  majority  of  cases,  the  mental  con-  , 
fusion  has  been  hallucinatory — that  is  to  say,  has  been  preceded  ; 
by  a hallucinatory  period  of  varying  intensity  and  duration,  of  j 
which  the  confusion  and  all  the  described  forms  of  acute  dementia,  I 
amentia,  etc.,  should  be  considered  as  concomitant  facts.  At  the 
same  time,  I do  not  deny  the  existence  of  a primary  confusion  not 
hallucinatory  in  origin,  but  this  primary  form  is  very  rare  in  com- 
parison with  the  other.  I 

The  disease  sometimes  commences  tumultuously  with  a few 
intense  hallucinations,  which,  as  a rule,  are  repeated,  or  with 
multiple  hallucinations,  varying  or  uniform,  which  surprise  the  con- 
sciousness in  its  full  vigour.  Much  more  commonly  it  is  preceded 
by  prodromata — bad  humour,  a general  indefinable  out-of-sorts  con- 
dition, increased  excitability,  loss  of  appetite,  headache,  insomnia, 
and  extravagant  conduct.  Then  come  upon  the  scene  kinaesthetic, 
tactile,  auditory,  visual,  or,  more  rarely,  olfactory  and  gustatory 
hallucinations,  in  single  succession  or  all  together.  In  the  first 
case  the  patient  assumes  an  attitude  of  suspicion — a vague  fear  ■ 
takes  hold  of  him,  and,  unable  to  find  an  explanation  for  his  new 
impressions,  he  becomes  self-concentrated,  solitary,  and  breaks  his  ! 
wonted  habits.  As  the  same  hallucinations  are  repeated,  he  is  f 
seized  with  real  terror.  Then  commences  the  period  of  psycho-  , 
motor  agitation,  the  intensity  of  which  varies  in  different  cases  ' 
within  very  wide  limits,  as  in  furor  and  in  acute  delirium.  ‘ 

Contemporaneously,  the  psychic  personality  is  more  or  less 
broken  up.  The  new  arrivals  in  the  consciousness  open  up  quite 
a new  world,  obscuring  and  eclipsing  the  real  in  varying  degree — a ■ 
world,  too,  in  which  the  old  personality  constantly  finds  itself  at  a | 
loss.  The  fresh  arrivals,  invading  and  encumbering  the  field  of  the  I 
consciousness,  hinder  the  formation  of  the  normal  products  of  i 
thought  and  the  regular  flow  essential  for  the  direction  of  the  j 
actions.  With  the  disaggregation  of  the  old  personality  there  is 
almost  always  incoherence  of  speech  and  action,  which  is  to  be 
regarded  as  the  immediate  externalization  of  the  various  hallucina- 
tions, as  they  gradually  gain  the  control  of  the  psychic  life.  To 
this  result  there  contribute  the  relative  emotive  conditions  which, 
free  from  any  restraining  influence,  resolve  themselves  into  a series 
of  actions  in  which  we  see  the  same  disorder,  the  same  incoherence, 
and  the  same  impulsiveness.  The  patiencs  are  a prey  to  strong 
motor  agitation,  in  which  in  the  gravest  cases  we  perceive  nothing 
intentional,  whilst  in  the  less  serious  cases  series  of  movements 
which  appear  to  be  performed  for  some  purpose  are  followed  by 
others  that  have  no  relation  with  the  preceding,  and  bear  the  stamp 
of  automatism  and  of  reflex  action. 


SENSORY  INSANITY 


721 


In  this  state  the  perceptive  process  cannot  be  realized  ; false 
judgments  are  formed  upon  everything  that  comes  under  the 
senses  of  the  patient.  Here  we  liave  not  so  much  a true  percep- 
tion as  a transitory  notice,  superficial  and  fragmentary,  followed 
by  illusory  judgment,  without  any  exertion  of  the  faculty  of  reflec- 
tion, which  is  either  defective  or  completely  wanting. 

The  greatest  dissociation  is  in  the  realm  of  the  ideas.  The 
ideative  capital  rendered  inert,  the  regular  flow  of  thought  hindered 
by  the  violent  intrusion  of  the  hallucinatory  products,  the  norm 
of  the  ideative  life  is  lost  sight  of,  and  substituted  by  that  of  such 
confused,  disordered,  and  illogical  sensory  images  as  the  sensory 
areas  of  the  brain  offer  to  the  dormant  consciousness. 

With  such  sensory  products,  lacking  any  associative  bond 
through  the  absence  of  any  directive  power  whatsoever,  with  the 
anomalous  associations  of  the  hallucinatory  products,  with  the 
fragmentary  ideas  and  emotional  states  induced  purely  by  the 
hallucinations  and  by  the  illusions  (the  more  intense  and  illogical 
these,  the  more  defective  the  control  of  the  higher  centres),  we  can 
readily  understand  to  what  degree  the  incoherence  in  speech  and 
action  may  attain. 

Xo  logical  connection  exists  between  the  psychic  manifestations. 
The  delirium,  an  expression  of  the  hallucinatory  content,  is  dis- 
connected, chaotic,  variable,  like  the  sensory  products  by  which 
it  is  maintained  and  the  fragmentary  reminiscences  that  the  hallu- 
cinations themselves  revive. 

With  this  psychic  condition  there  are  associated,  as  a rule, 
somatic  facts  of  no  small  value. 

The  temperature  is  sometimes  febrile  in  the  first  days  of  the 
attacks  ; the  pulse  becomes  feeble  and  rapid,  the  tongue  coated, 
the  breath  often  acetonic,  the  bowels  constipated ; there  is  anorexia 
and  often  refusal  of  food.  This  state  of  things  lasts  several  days 
or  weeks,  after  which  there  follows  a second  phase,  wherein  the 
dementia,  which  should  be  regarded  as  a concomitant  of  the 
preceding  hallucinatory  stage,  is  more  evident,  and  persists  for 
a longer  or  shorter  time,  during  which  the  hallucinations  and 
phases  of  psycho-motor  exaltation  are  repeated  with  varying  fre- 
quency. 

One  of  the  observations  which  I have  recorded  shows  clearly 
that  an  acute  hallucinatory  state  such  as  I have  described  above 
is  not  indispensable  for  the  production  of  grave  mental  confusion 
or  stupor.  Such  cases  are  very  frequent.  A single  hallucination, 
if  it  be  somewhat  intense  or  repeated,  may  be  quite  sufficient  to 
give  such  a result.  In  such  a case  it  would  appear  that  the  hallu- 
cination transports  the  consciousness  of  the  patient  into  the  regions 
of  the  wholly  unknown,  where,  no  longer  able  to  find  its  bearings, 
it  remains  suspicious,  uncertain,  and  confused,  until  it  finds  some 
loophole  of  escape,  or  a path  leading  back  to  the  old  world  with 

46 


722 


PSYCHIATRY 


which  it  is  familiar,  and  where  it  can  move  with  certainty  and| 
entire  freedom.  | 

Between  the  cases  of  acute  sensor}^  insanity  which  sometimes 
resembles  true  acute  delirium  and  those  in  which  the  malady  com-! 
mences  with  a few  intense  hallucinations,  or  with  fleeting  hallucina- 
tions that  exercise  a strong  suggestive  power,  followed,  moreover, 
by  a more  or  less  notable  degree  of  mental  dysorientation,  there  are 
numberless  gradations  in  which  the  hallucinations  are  many  or 
few,  and  the  agitation  is  wanting  or  the  incoherence  moderate. 
There  are  some  in  which  the  confusion  is  of  short  duration,  being 
followed  in  a few  days  by  convalescence,  and  later  by  complete; 
restoration  of  the  psychic  personalit}/.  | 

::  The  degree  of  confusion  varies  very  much  in  different  subjects,  i 

ranging  from  slight  dysorientation  to  the  most  complete  stupidity. 
There  are  patients  in  whom  we  hardly  notice  the  lowered  tone  of 
the  psychic  personality.  The  psychic  processes  are  somewhat 
slowed,  the  mnemonic  reproduction  difficult,  the  perception  less 
prompt,  and  often  erroneous,  especially  in  complex  positions.  Such 
are  distracted,  extravagant,  indifferent,  irritable.  Others,  again, 
are  caught  in  some  incoherence  of  speech  or  action,  sometimes 
illogical  or  impulsive,  or  they  are  heard  to  utter  fleeting  delirious.! 
ideas,  survivals  of  the  hallucinatory  products.  There  are  patients,  i 
too,  who  remain  for  a long  time  in  a state  of  complete  apathy  and,j 
indifference,  with  an  expression  midway  between  astonishment  andJ 
stupidity,  the  gaze  languid  and  expressionless,  the  limbs  relaxed,^i 
the  head  bent,  the  lips  half  open,  allowing  a continual  flow  of  saliva, ij 
immobile,  dirty,  and  oblivious  to  everything  that  goes  on  around'j 
them.  All  the  psychic  activities  are  suppressed  or  rudimentary,  j 
As  a rule,  also,  the  nutritive  functions  and  the  process  of  elimina- 1 
tion  become  sluggish  (D’  Ormea  and  Maggiotto)  ; the  patients- 
rapidly  lose  weight.  ^ 

If  one  of  these  patients  be  interrogated,  we  either  obtain  noj 
response,  as  though  we  had  not  spoken,  or  it  is  necessary  to  repeat, 
the  question  several  times  in  a loud  voice,  whereupon  we  see  him,| 
slowly  raise  his  head  oj  slightly  shrug  his  shoulders,  or  make  rudi- 
mentary movements  with  the  lips,  as  though  desirous  to  reply  and 
articulate  some  monosyllables  ; and  if  we  persist  still  further,  he 
may  succeed  at  first  in  formulating  a reply,  but  very  soon  falls  into 
errors  of  judgment,  or  assumes  theatrical  and  grotesque  poses. 

Between  these  two  extreme  degrees  there  is,  as  I have  said,  an 
infinite  variety  of  others.  In  some  the  prevailing  tone  is  melan- : 
cholia  rather  than  confusion,  it  also  being  provoked  by  the  content ; 
of  the  hallucinations,  and  the  consciousness  is  then  comparatively; 
lucid.  The  psychic  arrest  is  marked.  In  others  there  is  a pre- 1 
vailing  spirit  of  happiness,  and  then  they  sing,  whistle,  leap,  dart  I 
impulsively  here,  there,  and  everywheie,  then  stop  either  in  a; 
corner  or  beside  a window,  and  gaze  into  space,  or  stand  behind ' 


SENSORY  INSANITY 


723 


a door  in  the  strangest  and  most  irrational  attitudes.  Phases  of 
stupor  often  alternate  with  hallucinatory  phases,  or  with  numerous 
movements  more  or  less  irrational  and  impulsive.  These  patients 
sometimes  assume  mystic  religious  attitudes  ; at  other  times  they 
remain  in  a state  of  ecstasy,  with  almost  cataleptic  rigidity  of  the 
musculature  (katatonia)  ; yet  again,  they  exhibit  on  the  same 
stuporous  foundation  alternations  of  weeping  and  laughter,  instinc- 
tive brutish  impulses,  and  comparative  mental  lucidity.  Now  they 
show  stereotyped  features  which  are  residua  of  the  previous  hallu- 
cinations in  a brain  exhausted  and  prone  to  automatism,  now 
negativism,  now  deliria  with  a tendency  to  systematization,  in  due 
accordance  with  the  content  and  nature  of  the  hallucinations  with 
which  the  malady  begins.  All  these  states  may  follow  upon  or 
mingle  with  one  another.  In  all  there  is  evidence  of  the  dissocia- 
tion of  the  personality  in  varying  degree  and  in  all  respects — idea- 
tion, affectivity,  conduct,  etc. 

The  confusion  continues  for  a longer  or  shorter  time,  weeks  or 
months,  sometimes  even  years,  and,  according  to  the  primary 
cerebral  constitution,  the  ps3^chic  life  may  be  restored,  even  when 
the  malady  has  lasted  for  a very  long- time  (several  years). 

The  following  are  the  syndromes  that  have  received  different 
names  : acute  dementia,  amentia,  stupidity,  dementia  pi'cecox, 
katatonia  ; but  they  are  only  clinical  varieties  of  a single  morbid 
form — hallucinatory  insanity. 

As  regards  dementia  piaecox,  I find  no  sufficient  reasons  for 
elevating  it  to  the  position  of  a clinical  entity  ; it  is  an  offshoot 
rather  than  a disease,  and,  whether  it  develops  in  adolescence, 
youth,  or  maturity,  presents  no  difference  in  its  clinical  features. 
Confronted  with  a case  of  mental  confusion,  we  have  no  means  of 
deciding  whether  it  will  be  followed  by  recovery  or  pass  into  ter- 
minal dementia.  There  is  no  standard  to  guide  us,  no  feature 
presenting  a loophole  through  which  we  can  peer  into  the  future. 
One  case  of  profound  confusion,  with  vivid  and  multiple  hallucina- 
tions and  with  psycho-motor  agitation,  may  end  in  rapid  recovery, 
whilst  another  case,  in  which  the  clinical  picture  seems  identical 
in  its  general  features,  may  be  protracted,  and  later  on  com- 
plicated by  katatonia  or  paranoid  phenomena.  vSometimes  we 
have  a fortunate  termination  occurring  very  late,  after  several 
years,  even  when  we  have  unquestionably  had  the  clinical 
picture  of  dementia.  Amongst  other  cases,  I remember  that  of  a 
married  lady  who,  as  a result  of  an  acute  hallucinatory  psychosis, 
i presented  all  the  characteristics  of  dementia  praecox  — profound 
mental  confusion,  hallucinations,  impulses,  caprices,  phases  of 
j stupid  mirth  and  of  negativism,  occasional  refusal  of  food,  dreamy 
states,  personal  neglect,  total  loss  of  modesty  and  the  sense  of  de- 
cency, stereotypes,  and  filthy  habits.  Throughout  this  condition, 
lasting  for  about  five  years,  the  husband  was  very  anxious  for  me 

46 — 2 


724 


PSYCHIATRY 


to  give  a prognosis.  This  was  a very  delicate  matter,  inasmuch  as 
the  husband,  a workman,  wished  to  ascertain  whether,  for  the 
management  of  his  house  and  the  care  of  a numerous  family,  all 
young  children,  he  might  not  set  up  housekeeping  with  anothei 
woman. 

I expressed  my  opinion  as  regards  the  future  of  this  patient^ 
without  any  reserve,  deeming  recovery  far  from  probable.  As  a I 
matter  of  fact,  she  commenced  to  improve  after  several  months. : 


Her  hallucinations  disappeared  ; she  commenced  to  have  a true  and 

proper  conception  of  her  environment ; her 
ideas  gradually  became  regulated ; the  as- 
sociative bonds  of  her  personality  and  her 
memory  became  restored ; she  became 
m.odest  and  orderly  in  her  behaviour,  and 
desired  to  see  her  children  and  her  husband 
again.  Recovery  was  complete  in  the 
sixth  year. 

Ventra  (‘  Le  guarigioni  tardive  I etc.,  II 
Manicomio,  1890)  reports  some  very  interest- 
ing cases  of  late  recovery,  amongst  others 
being  some  of  sensory  insanity  (acute  de- 
mentia, amentia). 

The  case  above  referred  to,  like  many 
of  those  recorded  here,  and  in  common 
with  very  many  others  that  crowd  all 
asylums  for  the  insane,  presents  a perfect' 
resemblance  to  the  dementia  praecox  of 
adolescents.  x\s  a rule,  these  patients  are 
torpid,  have  a vacant  look,  an  expression- 
less physiognomy.  They  are  extremely 
forgetful,  indifferent  totheir  dearest  friends,' 
improper  in  their  conduct  ; their  clothes  arc 
torn  and  untidy,  the  hair  dishevelled,  the 
lips  apart,  allowing  the  saliva  to  trickle 
from  the  mouth  and  soil  the  clothing, 
mucus  is  constantly  running  from  the 
nose,  and  the  patients  are  either  voracious 
or  show  no  inclination  for  food.  They  understand  nothing ; the}' 
laugh  or  weep  in  a foolish  manner ; they  are  strange  in  behaviour, 
make  faces,  retain  the  saliva  in  their  mouths,  and  either  do  not 
speak  or  utter  stupid  phrases.  They  collect  everything  they  can 
lay  their  hands  upon — paper,  straw,  bread,  buttons,  filth  of  all 
kinds,  even  excrement — filling  their  pockets  with  them.  They  are 
liable  to  phases  of  agitation,  with  cries,  tendencies  to  tear  and 
destroy,  or  to  single  impulses.  Some  show  phases  of  excitement 
and  of  depression  (circular  form).  The  description  applies  equally 
to  adolescents,  youths,  and  adults. 


Fig.  94. — Sensory  In-7 
SANITY : Stupid  Form. 


i 


SENSORY  INSANITY 


725 


Dementia  praecox,  as  was  remarked  in  a recent  and  interesting 
monograph  by  Jahrmarker,  of  the  clinique  ot  Tuczeck,  is  met  with 
in  many  well-defined  maladies,  including  even  hysteria. 

The  peculiarities,  extravagances,  incoherences,  the  change  of 
character,  which  mark  the  commencement  of  dementia  praecox 
in  3muths,  when  not  preceded  by  an  acute  hallucinatory  phase,  are 
an  effect  of  sensory  disorders  which  escape  observation,  because, 
unless  specially  inquired  into,  they  are  not  brought  under  notice 
b\"  the  nurses  concerned.  They  are  vague  voices  that  break  in 
upon  the  consciousness  and  rupture  the  mental  unity,  heard  some- 
times in  the  body  (verbal  hallucinations),  and  leading  to  dysorienta- 
tion.  They  are  tactile  hallucinations,  profound  disturbances  of  the 
kinaesthesis,  that  alter  the  central  mechanism  of  the  personality  ; 
or  they  are  dreams  whose  influence  is  continued  into  the  waking 
state,  leading,  in  the  mind  already  preoccupied,  to  a certain  con- 
fusion between  the  real  and  the  unreal. 

Now,  the  inattention,  the  distractions,  the  fleeting  bewilder- 
ments, the  impulses,  the  varied  and  irrational  attitudes,  the  extra- 
vagances, the  eccentricities,  the  fleeting  and  paranoid  manifesta- 
tions, the  more  or  less  profound  alterations  of  the  character,  the 
dulling  of  the  intellect  and  affections,  the  neglect  of  personal  duties, 
the  insomnia,  the  isolation — in  short,  all  those  phenomena  char- 
acterizing hebephrenia,  which  gives  rise  to  the  majority  of  premature 
dementias,  have  a sensory  basis.  Accurate  inquiry  into  the  nature 
and  origin  of  those  facts  that  already  indicate  the  disintegration  of 
the  personality  alwa^^s  reveals,  with  very  rare  exceptions,  the 
existence  of  sensory  disturbances.  Here  we  have  to  deal  with  an 
increased  potential  of  the  sensory  centres  which,  discharging  itself, 
ruptures  the  relations  between  the  mind  and  reality,  and  puts  in 
motion  the  lower  motor  centres,  now  withdrawn  from  the  influence 
of  the  inhibited  controlling  and  regulating  capacities. 

Kraepelin  distinguishes  two  forms  of  dementia  praecox — the 
pure  form,  so  to  speak,  without  concomitant  symptoms,  and  con- 
sisting in  a progressive  diminution  of  the  mental  powers,  and  the 
others  in  which  the  dementia  is  rapidly  established,  but  preceded 
by  various  symptoms,  such  as  deliria,  hypochondriasis,  and  possibly 
hallucinations.  I doubt  the  existence  of  the  first  form.  Only  in 
one  or  two  cases  have  I not  succeeded  in  elucidating  the  hallucina- 
tory commencement  of  the  malady.  I cannot  even  agree  with 
Christian  {Annales  Med.  de  Psych.,  1899),  who  distinguishes  first 
an  initial,  then  a delirious,  and  finally  a third  period  of  dementia. 
The  dementia  is  initiated  with  the  confusion  and  the  deliria.  At 
most,  the  hallucinations  disappear  or  become  rare  in  the  long  run,  and 
the  deliria  become  less  pronounced,  whilst  the  dementia  progresses. 

The  following  is  one  case  amongst  many  in  which  the  malady 
was  initiated  not  by  an  acute  hallucinatory  phase,  but  by  sensory 
disorders  difficult  of  detection  : 


726 


PSYCHIATRY 


Observation  XXXIL— G.  G.,  aged  twenty-one ; both  parents  psycho- 
pathic. Patient  was  subject  to  convulsions  in  infancy.  He  showed  lively 
intelligence,  and  obtained  the  first  prizes  at  school.  Without  any  reason, 
he  commenced  to  behave  in  a strange  manner.  One  night  he  left  the 
house,  remained  out  all  night,  and  in  the  morning  said  that  he  had  been 
with  his  sweetheart.  As  a matter  of  fact,  he  had  wandered  about  the 
streets  the  whole  night  in  a dreamy  state,  behind  the  phantasm  of  his 
supposed  sweetheart.  He  did  not  remain  at  rest  in  any  position,  but 
showed  a marked  cortical  irritation,  was  violent,  and  offered  resistance 
when  being  examined.  From  the  first  days  he  was  detected  gazing 
towards  the  window  or  a high  point  in  the  room  ; he  laughed,  gesticulated, 
and  spoke  to  himself. 

This  is  a very  common  mode  of  commencement  of  the  dementia 
of  youth  (hebephrenia  and  dementia  prsecox),  and  it  is  clearly  of 
hallucinatory  origin.  No  doubt  remains  of  such  an  origin  when 
inquiry  is  made  into  most  of  the  cases.  The  difficulty  very  often 
lies  in  the  impossibility  of  making  a full  inquiry  into  the  history  of 
the  case. 

I report  here  the  case  of  a patient  who  sought  to  escape  from 
the  asylum  in  which  he  was  confined  : 

Observation  XXXIII. — G.,  aged  thirty-one,  coral  merchant. 
Mother  died  of  tuberculosis,  and  belonged  to  a family  with  hereditary 
taint  (one  brother  is  an  imbecile).  He  had  suffered  great  mental  worry  : 
owing  to  the  fact  that  he  had  repaired  to  Senegal  with  coral  goods, 
under  the  impression  that  they  were  not  liable  to  import  duty,  with  the 
result  that  the  goods  were  confiscated  and  the  patient  sent  back  to  his  ' 
country  by  the  Consul. 

Grief  and  misfortune  greatly  disturbed  his  mind.  Having  returned 
home,  he  felt  ‘ cannon-balls  ’ in  his  spleen.  Some  nights  he  did  not 
sleep,  and  felt,  as  it  were,  some  miasmas  produced  by  poisons  exhaling 
from  his  body.  One  night  he  left  home,  and  proceeded  as  though  he 
were  impelled  towards  the  house  of  a young  lady  for  whom  he  did  not 
care  much.  On  the  road  he  wished  to  stop,  but  a force  in  his  legs  and 
trunk  urged  him  on  towards  the  door  of  that  house  (kinaesthetic  hallu- 
cinations). 

Arrived  there,  he  saw  the  shadow  of  a doctor  from  his  district  ? 
extending  wires  from  the  balcon}^,  and  he  felt  those  wires  producing 
currents  on  his  face.  He  returned  home,  and  passed  several  da  vs  in 
solitude  in  a small  outhouse,  wrapped  in  deepest  thought.  One  morning, 
whilst  smoking  a cigarette  at  the  window,  he  perceived  a peculiar  odour, 
which  was  not  the  smell  of  anything  burning,  although  on  turning  round 
he  saw  that  his  bed  had  caught  fire,  and  at  the  same  time  heard  a voice 
saying  ; ‘ Put  all  your  clothes  on  the  fire  and  lie  down  yourself.  You 
will  not  burn.’  He  obeyed,  put  linen  and  other  clothing  on  the  fire,  laid 
himsed  down,  and  fell  into  a sort  of  sleep,  which  was  interrupted  by  the 
police,  who,  seeing  the  smoke,  or  previously  warned  by  the  neighbours, 
surprised  him  lying  in  bed.  whilst  a pile  of  linen  was  burning  in  the  room, 
now  filled  with  smoke.  He  was  taken  to  the  asvlum.  There  he  has 
always  been  gloomy,  morose,  and  solitary  in  behaviour  (melancholic 
variety  of  acute  dementia).  He  is  indolent,  and  rather  fond  of  lying 
in  beck  Sometimes  he  is  detected  speaking  to  himself  ; at  other  tunes 
a smile  breaks  the  stereotyped,  indifferent  expression  of  his  features. 

One  day  he  forced  open  a door  communicating  with  a flight  of  steps 
leading  to  a disused  cellar.  Descending,  he  prised  open  a window. 


SENSORY  INSANITY 


727 


removed  it  from  its  hinges,  as  if  with  the  object  of  making  his  escape, 
but  at  this  point  stopped. 

He  did  not  run  off,  he  did  not  turn  back,  nor  did  he  present  himself 
at  the  dinner-table  ; he  did  not  call,  he  made  no  outcry,  but  remained 
there  all  night,  and  was  found  there,  cold  and  famished,  the  following 
day.  He  confessed  that  he  had  heard  a voice  shouting  to  him  : ‘You 
will  never  get  away  from  here,’  and  on  this  account  he  attempted  to 
escape.  His  courage  failed  by  the  way,  and  the  project  was  abandoned. 

He  is  capable  of  formulating  brief  phrases,  but,  when  left  to  speak 
for  himself,  he  enters  upon  an  incoherent,  confused  discourse,  crammed 
with  neologisms,  and  formed  of  phrases  without  connection  and  with 
obscure  meaning,  always  reflecting  his  hallucinatory  products.  This  is 
another  example  of  dementia  pr?ecox. 

We  might  assign  a nosological  dignity  to  dementia  praecox 
did  the  malady  make  its  appearance  with  the  same  features 


Fig.  95. — Sensory  Insanity  : Katatonic  Form. 

as  characterize  its  culmination  and  termination,  or  were  these 
characteristics  of  such  a nature  that  clinical  investigation  would 
afford  an  indication  of  their  existence  before  they  might 
appear  with  their  full  signification  in  the  course  of  the  disease, 
of  which  dementia  prcecox  often  constitutes  the  final  issue.  Most 
accurate  inquiries,  however,  into  the  morbid  manifestations  of 
those  patients  whose  illness  has  been  followed  for  a long  period 
have  not  permitted  me  to  formulate  any  law  of  succession  which 
will  enable  one  to  decide  beforehand  whether  the  particular  form 
of  mental  confusion  will  end  in  dementia  or  in  recovery. 

Even  when  we  have  had  under  examination  patients  of  the 
same  age  and  of  the  same  culture — for  example,  two  municipal 
teachers — we  have  not  been  able  to  foresee  why,  under  the  same 
conditions  of  environment  and  of  treatment,  in  the  one  we  should 
have  progressive  restoration  of  the  mental  activities  and  recovery 


'A 


728  PSYCHIATRY 

on  cessation  of  the  hallucinations,  whilst  in  the  other  we  should 
have  the  confusion  prolonged  and  accompanied  by  all  the  features 
of  dementia  praecox.  I 

Now,  if  the  so-called  dementia  praecox  is  not  a disease,  but  a 
syndrome  that  is  often  terminal,  as  Kraepelin  himself  has  often 
clearly  stated ; if  it  cannot  be  recognised  by  any  characteristics 
m the  morbid  phases  preceding  it,  if  we  except  phenomena  of  con- 
fusion, of  mental  dissociation,  and  the  hallucinations,  disconnected 
in  some,  but  in  typical  cases  suggestive  and  determinative,  I find 
no  justification  for  that  denomination,  except  in  so  far  as  it  indi- 
cates a form  of  sensory  insanity  of  youth  which  was  included  in 
the  conception  of  hebephrenia  (vide  Seppilli,  Atti  del  V.  Congresso 
della  Societd  Fren.  Ital.,  1886).  In  many  other  cases  that  name 
corresponds  to  the  old  ‘ consecutive  dementia.’ 

It  is  to  be  added  that  the  symptoms  of  dementia  praecox  are  not 
peculiar  to  it  alone,  but  belong  also  to  the  confusional  states  of 
youth  and  to  many  other  morbid  states — hysteria,  epilepsy,  organic 
diseases  of  the  brain  and  also  for  this  reason  there  is  no  evident 
need  for  a new  nomenclature. 

Not  even  on  the  grounds  of  a previous  state  of  developmental’ 
mental  weakness  in  an  individual  who  becomes  a subject  of  sensory 
insanity  while  still  young,  can  we  base  an  argument  for  the  fore-  . 
telling  of  the  final  issue  of  a malady  whose  chief  characteristics  • 
consist  in  confusion  along  with  hallucinations.  The  issue  in  a well- 
developed  and  cultured  individual  may  be  one  of  dementia,  and  in  t 
a deficient  or  illiterate  person  it  may,  on  the  contrarv,  be  one  of 
recovery. 

The  only  fact  which  allows  us  to  foresee  a termination  in  irre- , 
parable  dementia  is  the  deceptive  commencement  of  the  disease,  • 
especially  if  complicated  at  an  eaily  stage  by  the  katatonic  syn- 
drome,  when  the  latter  is  not  of  a distincth^  hysterical  nature. 

Were  this  book  not  a treatise  for  practitioneis  and  students,  a '' 
reason  that  prevents  a long  discussion  of  the  facts  and  also  a review  * 
of  the  opinions  of  many  others,  thus  bringing  them  before  the  reader, 

I might  give  a fuller  exposition  and  criticism  of  this  question. 
Altogether,  Kraepelin’s  doctrine  has  found  ardent  supporters  and 
opponents,  and  has  won  many  positions  in  the  field  of  literature 
(vide  Finzi,  Vedrani,  Mandalari,  ‘ La  dementia  prcecox,^  Messina, 
1903;  Jahrmarker,  ‘ Zur  Frage  der  Dementia  prcecox'  Hall,  1903; 

P.  Serieux,  Revue  de  psychiatrie,  1902  ; Seylus,  ‘ Nouvelle  Icono- 
graphie  de  la  Salpetriere,'  1902  ; Serbsky,  Journal  of  Mental  Patho- 
logy, vol.  ii.,  1903  ; Del  Greco,  ‘ Sidle  varie  forme  di  confusionc 
mentale,^  1S97). 

Katatonia  is  another  of  the  forms  that  sensory  insanity  assumes. 

It  is  merely  acute  dementia,  amentia,  or  dementia  praecox,  with 
symptoms  of  muscular  rigidity  on  passive  movement,  waxen 


SENSORY  INSANITY 


729 


flexibility,  cataleptiform  states,  hypertonicity,  strong  resistance  to 
movements  impressed  on  any  part  of  the  body.  Here  also  we  find, 
more  or  less  accentuated,  all  the  other  symptoms  of  dementia 
prsecox — stereot}^pism,  negativism,  but  especially  stupor,  verbigera- 
tion, echolalia,  echopraxia.  Sometimes  there  are  melancholic  states, 
alternating  with  superexcitation,  exaltation,  stupor,  and  mutism 
(circular  or  maniacal-depressive  form  of  katatonic  sensory  insanity). 
During  this  phase  we  frequently  meet  with  refusal  of  food,  reten- 
tion or  involuntary  loss  of  urine  and  faeces,  extravagant,  theatrical, 
sometimes  ecstatic  poses,  with  alternations  of  singing,  leaping,  and 
running.  Often  the  patients  break  out  into  impulsive  actions, 
breaking  and  destroying  things,  performing  childish  actions,  or 
assuming  inquisitive  and  inquiring  attitudes.  For  example,  they 
roll  about  on  the  ground,  squat  down  under  the  beds,  and  occupy 
the  beds  of  other  patients.  Sometimes  they  exhibit  convulsive 
attacks,  ^^ery  frequently  there  are  hallucinations,  delirious  mani- 
festations of  erotic,  persecutory,  or  religious  content,  especially  in 
women  after  parturition  (puerperal  insanity).  There  is  always 
grave  mental  dissociation  (confusion),  and  particularly  stupor. 
The  physiognomy  is  as  expressionless  as  a mask,  and  yet  there 
may  be  reason  to  fear  impulsive,  aggressive  actions.  In  this  state 
we  may  put  the  patient  in  any  position  we  desire,  and  he  maintains 
it,  even  though  it  be  very  inconvenient. 

These  are  the  clinical  features  of  katatonia  ; they  are  those  of 
acute  dementia,  or  dementia  prsecox  along  with  katatonic  symp- 
toms. As,  however,  katatonic  symptoms  are  met  with,  not  only 
in  dementia  praecox,  but  also  in  other  affections,  such  as  hysteria, 
melancholia,  epilepsy,  senile  dementia,  katatonia  cannot  be  a 
disease  in  itself,  but  rather  a symptomatic  complexus.  The  kata- 
tonic symptom  becomes  engrafted  on  more  or  less  profound  con- 
fusion irrespective  of  origin,  but  it  is  more  frequent  in  young  people 
and  in  females.  It  is  the  expression  of  a particular  idiosyncrasy. 

The  most  classic  forms  of  acute  dementia  (dementia  praecox  ?) 
present  katatonic  symptoms  in  only  a small  proportion.  In  every 
case  we  have  to  deal  with  a dreamy  condition  resembling  induced 
somnambulism,  in  which  the  directive  power  of  a higher  centre  of 
the  psychic  life  is  wanting,  and  the  consciousness  is  animated  only 
by  the  sensory  products,  which  represent,  as  it  were,  the  dream 
induced  in  the  somnambulist.  Hence  results  the  suggestivity 
which  arises  from  the  increased  potential  of  the  lower  motor  centres. 

That  this  suggestivity  is  more  common  in,  and  more  charac- 
teristic of,  hysteria  no  one  can  deny  ; but  the  manifestation  of 
katatonic  phenomena  in  young  people  who  have  never  been  hysterical, 
who  have  never  shown  hysterical  signs,  who,  on  the  contrary,  liave 
manifested  from  the  very  outset  the  marks  of  dementia  prsecox, 
and  have  not  recovered,  compels  us  to  exclude  the  hysterical 
nature  of  katatonia  in  some  cases.  The  psycho-somatic  conditions 


730 


PSYCHIATRY 


of  hysteria  are  no  doubt  repeated,  but  on  a different  foundation, 
and  with  quite  a different  structure. 

The  hypothesis  of  Chaslin  and  Seglas  may  be  considered  well 
founded  in  so  far  as  a certain  number  of  cases  of  katatonia  are  of 
hysterical  nature  (hysterical  insanity),  and  are  quite  distinct  from 
those  of  purely  sensory  origin.  Madia  and  Patini  {Annali  di 
Neurologia,  1903),  in  their  interesting  memoir  on  katatonia,  in  seven 
cases  studied  in  my  clinique,  obtained  no  trace  of  hallucinatory 
phenomena.  The  truth  is  that  the  inquiry  is  very  difficult,  and  the 
hallucinatory  initiation  sometimes  escapes  observation.  The  future 
alone  will  reveal  the  true  succession  of  the  phenomena,  and  the  real 
nature  of  katatonia,  which  is  only  a modality  of  an  affection  of 
varying  nature. 

Confusion  is  not  the  only  phenomenon  that  may  follow  in  the 
wake  of  the  primary  hallucinatory  phase  already  described.  We 
may  have  another  issue — namely,  a systematized  delirium  (paranoid 
sensory  insanity,  paranoid  dementia  prsecox).  I have  observed 
several  such  cases,  amongst  them  the  following  : 


Observation  XXXIV. — P.  G.  belongs  to  a neuropathic  family 
and  is  married  to  a working  woman  in  poor  circumstances.  He  has 
lived  a rather  irregular  life.  His  illness  commenced  in  an  acute  manner 
five  or  six  days  before  admission  (October,  i8go)  with  visual  hallucina- 
tions of  saints,  extravagant  conduct,  insomnia,  delirious  ideas  of  grandeur, 
and  restlessness,  succeeded  in  a short  time  by  intense  agitation.  On 
the  day  of  admission  to  the  wards  he  looked  dazed  and  frightened  ; he 
was  confused,  and  hardly  gave  any  response  to  questions  put  to  him. 
After  several  days  of  hallucinatory  agitation,  accompanied  by  the  con- 
fusion just  mentioned,  there  followed  a period  of  calm,  during  whicli 
he  seemed  to  be  improving.  By  degrees,  however,  he  assumed  a proud 
and  haughty  demeanour.  He  avoided  entering  into  conhdence  with 
anyone  whomsoever,  and  to  the  medical  officers  merely  expressed  his 
desire  for  liberty.  If  he  met  with  any  obstacle  to  his  desires,  he  assumed 
a hostile  attitude,  raised  his  voice  to  a high  pitch,  and  even  used  abusive 
language  towards  the  staff.  The  confusion,  which  in  the  first  days  was 
considerable,  gradually  disappeared,  so  that  the  patient  came  to  recog- 
nise clearly  that  he  was  in  an  asylum,  and  to  form  a fairly  accurate  esti- 
mate of  many  objects  as  well  as  persons  in  his  new  environment. 

It  is  true  that  the  perceptions  were  a little  slow  and  the  judgments 
superficial,  a signihcant  fact  when  it  is  considered  that  the  patient  was 
a municipal  employe,  and  acted  as  vice-secretary.  He  also  showed 
difficulty  in  the  association  of  ideas,  and  soon  became  tired,  so  that  his 
mental  resource  appeared  progressively  weaker  the  longer  the  conversa- 
tion was  sustained.  In  spite  of  this,  and  notwithstanding  the  ready 
exhaustibility  of  his  ]ierceptive  power,  he  showed  a fair  mental  lucidity. 
He  had  a good  and  accurate  appreciation  of  all  his  past  life,  while  his 
recollection  of  the  period  from  the  commencement  of  his  illness  till  within 
a few  days  before  he  actually  came  under  examination  was  fragmentary 
and  confused.  For  example,  he  did  not  know  precisely  how  long  he 
had  been  in  the  asylum,  or  by  whom  and  for  what  reason  he  had  been 
taken  there. 

Apart  from  this,  reflecting  as  it  does  the  period  of  hallucinatory  con- 
fusion, he  showed  a fair  lucidity  in  other  respects.  In  proportion,  how- 


SENSORY  INSANITY 


731 


ever,  as  his  consciousness  became  clearer,  there  became  apparent  a new 
guest — a delirium  of  grandeur,  the  stable  residuum  of  the  hallucinatory 
products  which  had  invaded  his  mind  some  weeks  previously.  He 
desired  to  obtain  his  liberty,  because  ‘ as  soon  as  he  was  free  he  would 
be  able  to  acquire  millions’;  ‘his  father  was  a millionaire,’  and  ‘his  aunt 
was  worth  a couple  of  millions.’  He  could  give  no  explanation  of  the 
source  of  these  boasted  riches,  and  merely  said  ; ‘ The  revelation  of  that 
wealth  and  of  the  gold  which  I possess  came  to  me  in  a dream.’ 

Thenceforward  this  patient  has  remained  under  our  care,  and  to  see 
him  at  present  one  might  fancy  him  to  be  a pure  and  primary  paranoiac, 
in  the  face  of  complete  evolution  of  the  delirium,  with  incipient  mental 
enfeeblement.  On  the  contrary,  he  is  suffering  from  paranoia  consecu- 
tive to  acute  sensory  delirium.  He  has  shown  phases  of  aggravation 
and  of  comparative  lucidity,  besides  episodes  of  dangerous  impulses,  as 
frequently  happens  amongst  those  who  are  subject  to  hallucinations. 

Thus,  for  example,  on  December  21,  1891,  whilst  in  a state  of  calm, 
he  was  seized  by  a sudden  impulse,  and  without  any  reason  rushed  upon 
two  patients,  giving  each  a blow.  On  December  24  he  pitched  bowls 
and  plates  out  of  the  window  on  the  spur  of  the  moment,  calling  out 
that  women  and  children  were  below,  and  they  did  not  want  him  to 
see  them. 

In  May,  1893,  he  entered  upon  a new  period  of  confusion  consecutive 
to  hallucinations,  with  very  marked  incoherence  in  speech  and  action, 
as  well  as  in  the  delirious  ideas.  From  time  to  time  his  state  of  calm 
was  disturbed  by  very  vivid  hallucinations.  In  this  phase  he  expressed 
his  ideas  and  fell  into  continual  contradictions  in  actions  and  in  speech. 
On  other  occasions  he  was  almost  as  amenable  as  a child. 

In  December,  1894,  on  the  basis  of  confusion,  which  may  be  con- 
sidered as  a hallucinatory  dementia  prsecox,  a delirium  of  a grandiose 
nature  broke  out  again,  analogous  to  that  shown  in  the  hrst  phase  of 
the  illness,  except  that  it  is  now  more  paradoxical,  more  disconnected, 
closely  resembling  that  of  paralytic  dementia,  which,  however,  could  be 
absolutely  excluded. 

We  may  consider  the  above  case  as  one  of  paranoia  consecutive 
to  hallucinatory  confusion,  and  as  a more  stable  product  of  the  hallu- 
cinations of  the  first  period  of  the  illness  up  till  May,  1893.  As 
recovery  did  not  take  place,  the  disease  was  continued  into  dementia, 
the  ultimate  issue  of  all  psychopathies  that  do  not  end  in  recovery. 

In  another  group  of  cases  the  comparatively  systematized 
paranoid  delirium  is  maintained  by  active,  uniform  hallucinations, 
consecutive  to  an  acute  hallucinatory  phase. 

Observation'  XXXV. — Lan.  L.  fu  Antonio,  of  Naples,  aged  sixty- 
seven,  single,  admitted  April  8,  1893,  and  readmitted  October  2 of  same 
year. 

Nothing  is  known  of  her  family  history  beyond  the  fact  that  her  mother 
had  twenty- three  children,  of  whom  she  is  the  sole  survivor.  ■ All  the 
others  died  at  an  early  age. 

She  appears  to  have  always  enjoyed  good  health  until  a few  days 
before  her  first  admission  to  the  wards.  Beyond  a slightly  exaggerated 
tendency  to  religious  practices,  on  which  account  she  was  commonly 
called  ‘ The  Devout,’  she  has  never  shown  signs  of  mental  disturbance. 

We  have  no  precise  information  relating  to  the  period  immediately 
preceding  the  invasion  of  the  illness.  She  herself  says  that  she  had 
some  cause  for  dispute  with  a neighbour,  with  whom  she  had  always  been 


732 


PSYCHIATRY 


on  good  terms.  She  commenced  to  call  out  that  this  person  wished  to 
poison  her  with  a syringe  full  of  poison,  and  that  she  had  partly  effected 
her  purpose,  because  she  already  felt  symptoms  of  poisoning.  The 
hallucinations  and  the  disturbances  of  thought  accompanying  them 
increased  to  such  an  extent  that  her  removal  to  the  asylum  was  urgently 
called  for. 

Since  admission  to  the  asylum  the  progress  of  the  patient  has  been 
as  follows  : 

At  first  she  appeared  stupid,  incoherent,  had  no  proper  appreciation 
of  her  new  position,  and  responded  only  in  monosyllables,  or  at  most 
with  some  stunted  phrases,  to  the  various  questions  put  to  her.  Only 
sometimes  did  she  assume  an  attitude  of  apparent  fear,  for  which  no 
definite  reason  could  be  ascertained. 

After  several  days  a moderate  degree  of  improvement  was  noted  in 


Fig.  96. — Paranoid  Sensory  Insanity. 

the  Ipsychic  manifestations.  The  perceptions,  however,  were  imperfect, 
the  judgments  very  superhcial,  the  credulity  facile,  the  defects  of  criticism 
marked,  reaction  rather  slow  and  difficult,  as  was  also  the  manifestation 
of  the  psychic  activities  in  general.  After  some  time  hallucinations  with 
almost  uniform  content  again  became  pronounced.  Thenceforward  the 
patient  has  remained  in  an  almost  stationary  condition.  The  funda- 
mental disturbance  consists  in  sensory  disorders  and  a systematized 
delirium.  Here  we  have  to  deal  almost  exclusively  with  auditory  hallu- 
cinations that  have  remained  over  from  the  primary  acute  hallucinatory 
phase,  which,  owing  to  the  very  vivid  nature  of  the  image  and  the  feeble 
critical  capacity  of  the  patient,  are  accepted  as  actual  facts,  and  com- 
pletely deceive  her  consciousness. 

Every  day  she  is  found  seated  near  one  of  the  beds — always  the  same 


SENSORY  INSANITY 


733 


— in  her  ward,  fixing  all  her  attention  on  one  of  the  large  windows. 
Her  physiognomy  and  attitude  are  those  of  one  listening  to  a distant 
sound,  and  from  time  to  time  she  is  observed  signifying  agreement  or 
the  reverse  with  movements  of  her  head,  or  she  rises  and  turns  her  ear 
in  a certain  direction,  as  if  to  hear  more  distinctly.  If  she  is  taken 
away  from  that  seat  she  is  disconcerted,  and  at  first  seeks  refuge  in  dis- 
simulation, then  ends  by  confessing  that  a lady  of  her  acquaintance 
comes  there  every  day  to  visit  her.  She  hears  her  voice  with  the  greatest 
distinctness  coming  both  from  the  walls  and  from  the  garden,  and  has  no 
doubt  as  to  what  she  says.  This  lady  seems  to  repeat  to  her  : ‘ Why 
don’t  you  leave  this  place  ? You  are  expected  at  my  house,’  and  then 
proceeds  to  give  her  an  account  of  current  events  and  to  form  projects 
(of  an  amorous  content)  for  her  freedom.  She  does  not  see  the  said 
person,  but  the  latter,  she  argues,  must  see  her,  because  she  often  says  : 

‘ Why  do  you  blush  ? Why  are  you  so  pale-faced  to-day  ?’  The  tone 
of  her  personality  when  she  confides  her  hallucinations  to  others  changes. 
She  puts  on  the  air  of  a young  coquette  rather  ridiculous  at  her  age. 
Notwithstanding  that  she  is  prevented  from  sitting  near  the  particular 
bed  and  is  removed  from  it  every  time  she  is  caught  there,  she  always 
returns  whenever  she  can  elude  the  vigilance  of  the  nurses. 

For  some  time  she  has  no  longer  shown  any  reserve  in  revealing  the 
content  of  her  hallucinations.  She  now  engages  in  conversations  in  a 
loud  voice  with  the  person  who  she  believes  comes  to  visit  her.  She 
rebels  if  anyone  takes  her  away.  A true  delirium  of  prevailingly  erotic 
content  is  organized  upon  the  sensory  disturbances  mentioned  She 
proclaims  aloud  that  the  nurses  are  jealous  of  her  good  fortune.  She 
believes  that  when  she  leaves  the  asylum  she  will  marry  a young  gentle- 
man selected  for  her  by  that  same  lady. 

Indeed,  her  critical  capacity  is  even  weaker,  and  dementia  more 
marked.  She  is  always  uttering  the  same  delirious  ideas  in  an  apathetic 
manner,  and  these  are  becoming  weaker,  and  sometimes  entirely  dis- 
appear, when  the  hallucinations  are  not  repeated  for  some  time.  The 
latter,  however,  although  less  frequent,  still  present  themselves  in  a 
vivid  manner  from  time  to  time,  and  represent  a still  very  active  part 
of  the  psychic  functionality.  One  night,  for  example,  she  took  to 
calling  out  : ‘ Go  away  ! Don’t  insult  me  ! I don’t  know  what  you  are 
talking  about  !’ 

In  this  case  we  have  a true  systematized  delirium  induced  and 
maintained  by  hallucinations,  and  commencing  as  an  acute  form 
of  sensory  insanity. 

Sometimes  the  disease  commences  with  vague  kinaesthetic 
hallucinations  — depression,  concentration,  extravagances,  para- 
doxical interpretations  of  internal  sensations. 

A true  hypochondriacal  delirium  is  set  up.  The  patients  feel 
a suction  at  the  brain,  the  spleen  being  torn  away,  worms  under 
the  scalp  and  in  the  cranium. 

If  auditory  hallucinations  complicate  the  hypochondriacal 
delirium,  which  is  now  very  pronounced,  momentary  manifestations 
of  vague  disconnected  deliria  with  religious  or  demoniacal,  or 
even  persecutory  or  grandiose,  content  are  added.  In  this  state 
the  patients  are  dangerous,  owing  to  impulses,  outbursts,  tendency 
to  suicide  and  to  crime.  Phases  of  excitement  alternate  with 
phases  of  stupor,  sometimes  accompanied  by  katatonic  phenomena. 


734 


PSYCHIATRY 


The  malady  proceeds  in  this  manner  for  many  months,  and 
sometimes  for  a year  or  two,  at  one  period  with  a prevalence  of 
hypochondriacal  deliria  (hypochondriacal  paranoia  of  some  authors), 
at  another  with  prevalence  of  the  syndrome  of  dementia  (paranoid 
dementia  praecox),  and  then  ideas  of  grandeur  gradually  present 
themselves,  at  first  vague  and  fleeting,  afterwards  more  stable  and 
organized. 

These  deliria,  resembling  those  of  paralytic  dementia,  whilst 
they  impress  a different  attitude  on  the  patient,  who  up  till  now 
has  been  rather  dull  and  distressed,  mingle  with  the  hypochondriacal 
and  the  persecutory  deliria.  Here  also,  according  to  Magnan,  the 
evolution  of  systematized  deliria,  under  another  form,  is  sometimes 
evident  ; but  meanwhile  the  mind  becomes  more  impoverished,  the 
dissociations  more  marked,  the  affective  dulness  greater,  even  the 
delirious  ideas  losing  their  colour,  and  thus  there  is  set  up  an  ever- 
increasing  profound  terminal  dementia. 

In  my  opinion  the  paranoid  premature  enfeeblement  described 
by  some  authors  (recently  also  by  Lugaro)  comprises  not  only  the 
hypochondriacal  variety  above  described,  but  all  the  others  to 
which  I have  alluded,  and  which  are  best  included  under  the  title 
of  paranoid  sensory  insanity. 

It  sometimes  happens  that,  when  the  acute  hallucinatory  phase, 
the  duration  of  which,  as  we  know,  varies  greatly  in  different  cases, 
has  passed  away,  the  consciousness  is  at  first  clouded,  and  then 
becomes  clear  ; the  intelligence,  affected  from  the  outset  by  the 
most  evident  dissociation,  becomes  restored : there  remains,  however, 
for  a longer  or  shorter  time  a notable  weakness  of  the  will,  a true 
hypobulia,  and  a marked  emotivity,  with  corresponding  impul- 
sions which  present  the  same  features  as  the  hallucinations  by 
which  they  were  first  determined.  The  given  impulsions  are  either 
the  immediate  effect  of  rudimentary  hallucinations  or  of  fleeting 
illusions,  or  they  are  to  be  considered  as  an  effect  of  the  discharge 
of  the  nerve-waves  from  the  sensory  elements,  where  former  ten- 
sions are  from  time  to  time  revived,  and  whence  they  discharge 
themselves  directly  into  the  cortical  motor  zone,  without  interven- 
tion of  the  higher  co-ordinating  centres.  This  interpretation  is  quite 
admissible  when  we  recollect  the  facility  with  which  volitional 
nerve-waves  in  weak  personalities  pass  into  automatic  nerve- 
waves,  and  it  is  quite  probable  when  we  take  into  account  the 
relations  established  by  the  disease  between  sensory  zone  and  motor 
zone  {vide  Scheme,  p.  107). 

.Etiology. — Sensory  insanity  is  the  most  authentic  representa- 
tive of  the  gi'oup  of  psychoses  due  to  endogenous  intoxication  and 
infection.  All  that  we  have  said  in  speaking  generally  of  this 
group  is  applicable  to  sensory  insanity.  In  support  of  the  toxic 
or  infective  genesis,  we  have,  in  addition  to  all  we  know  in  a general 


SENSORY  INSANITY 


735 


way,  the  results  of  direct  bacteriological  investigations,  which  in 
many  cases  have  revealed  the  presence  in  the  blood  of  various 
streptococci,  staphylococci,  and  diplococci.  These  micro-organisms 
are  found  more  especially  at  the  commencement  of  the  disease, 
disappearing  later  on  recovery.  We  must  not  forget,  however, 
that  amongst  all  the  origins  of  the  intoxications  the  brain  itself 
is  of  no  small  importance.  Cerebral  exhaustion,  scanty  nutrition, 
loss  of  sleep,  are  amongst  the  most  frequent  causes  of  the  hebe- 
phrenic form  of  sensory  insanity  amongst  students.  Needless  to 
add,  the  factor  of  predisposition  always  comes  into  play.  At  a 
meeting  of  the  British  Medical  Association  in  igoi,  Robertson 
declared  with  his  unquestionable  competency  that  the  principal 
factors  in  the  genesis  of  the  acute  and  chronic  diseases  are  the 
various  forms  of  gastro-intestinal  toxaemia,  and  that  many  mental 
affections,  such  as  mania,  melancholia,  and  dementia  praecox,  must 
be  put  down  to  this  pathogenesis.  In  every  case  I have  been  able 
to  obtain  evidence  of  hereditary  predisposition. 

Of  the  infective  diseases  influenza  is  certainly  the  most  insidious 
as  a cause  of  this  acute  psychosis. 

The  pathological  anatomy,  so  far  as  we  know,  differs  in  no  way 
from  that  of  mania  and  melancholia.  In  acute  cases  the  alteration 
consists  of  chromatolysis  and  minute  alterations  of  the  vessel  walls. 
There  is  no  doubt,  however,  that  Nissl’s  method  is  insufficient, 
whilst  the  more  recent  methods  that  reveal  the  neuro-flbrillar 
structure  of  the  cell  have  not  yet  been  employed  in  the  various 
forms  of  acute  sensory  insanity.  Colucci’s  researches  deal  with 
chronic  psychoses  (dementias). 

Diagnosis. — The  clinician  can  meet  with  no  difflculty  in  diagnos- 
ing acute  sensory  insanity  from  mania.  The  cheerful  tone  of 
mind,  the  super-excitement  of  all  the  psychic  activities,  the  exalta- 
tion of  the  real  personality,  the  promptness  and  fidelity  of  the 
mnemonic  reproduction,  the  sometimes  ready  judgments,  the 
absence  of  true  hallucinations,  the  prevalence  of  illusory  interpre- 
tation, of  actual  stimuli,  permit  us  in  most  instances  to  distinguish 
without  much  difficulty  mania  from  acute  sensory  insanity,  the 
prevailing  features  of  which  are  the  confusion  and  the  sense  of  fear 
arising  from  the  hallucinations,  which  may  almost  always  be  readily 
detected  as  a prevailing  symptom  of  the  disease. 

Greater  difflculty  is  encountered  in  the  distinction  between  acute 
sensory  insanity  and  the  initial  hallucinatory  phase  of  progressive 
paralysis. 

Undeniably  there  are  cases  of  this  last-named  affection  that 
commence  with  an  acute  hallucinatory  form,  and  present  in  their 
later  course  hallucinatory  phases.  In  this  case  there  is  no  real 
difflculty  in  the  diagnosis  when  the  disease  is  somewhat  advanced ; 


736 


PSYCHIATRY 


but  when  progressive  paralysis  commences  in  this  manner,  thei 
clinician  will  only  in  rare  instances  be  able  to  discover  at  the  outsell 
the  true  nature  of  the  disease,  more  particularly  when  the  charac- 
teristic progressive  symptoms  of  progressive  paralysis  are  not) 
associated  with  the  symptomatic  complex  that  is  mistaken  for,^ 
sensory  insanity.  The  diagnosis  is  easy  when  the  hallucinatory! 
delirium  occurs  immediately  or  soon  after  an  apoplectiform  or; 
epileptiform  attack.  In  all  other  cases  it  is  best  to  await  the:, 
ulterior  development  of  the  disease,  with  its  manifestation  of  new! 
features,  which  will  eliminate  any  diagnostic  doubt  whatsoever. i' 
No  less  difficult  is  the  distinction  between  melancholia  attonitajl 
and  the  stupor  consecutive  to  the  hallucinatory  period  of  the: 
disease.  If  we  see  two  patients,  one  suffering  from  melancholia  I 
attonita  and  the  other  from  stupor,  it  often  happens  that  wef 
cannot  make  out  the  true  nature  of  the  disease.  Both  are  pale,  ii 
both  have  an  undecided  look,  both  have  withdrawn  themselves ) 
to  a corner  of  the  day-room,  both  are  untidy  in  their  personal ; 
appearance,  and  seemingly  indifferent  to  all  that  is  going  on  around  t 
them,  both  refuse  food ; nevertheless  the  two  diseases  are  essentially  if 
different.  The  difficulty  is  increased  when,  after  some  months,  the; 
melancholiac  loses  that  attitude  denoting  suffering  or  fear,  and  that  |. 
rigidity  of  the  physiognomy  that  is  peculiar  to  the  earliest  period, t 
of  the  disease.  The  contraction  of  the  pupil  in  the  melancholiac 
and  the  dilatation  in  the  stuporous  patient,  which  by  some  authorities^ 
have  been  regarded  as  differential  signs,  a certain  degree  of  muscular  ^5 
rigidity  in  the  former  (hypertonia)  and  atony  in  the  latter  are  signs  1 
of  no  great  value,  especially  under  the  conditions  I have  indicated.  » 
On  the  other  hand,  we  must  not  forget  that  there  are  cases  of;j 
hallucinatory  stupor  in  which  we  get  muscular  hypertonia  and  con-^1 
tracticn  of  the  pupil,  as  in  melancholia  attonita,  even  to  the  extent;'] 
of  the  classic  form  of  katatonia.  ^ 

In  these  cases  prolonged  observation  of  the  patient  will  furnish  v 
valuable  data  for  the  diagnosis  of  the  disease.  The  sudden  impulses,  'li 
the  stupid  smile  that  sometimes  flickers  over  the  face,  marble-like  1^ 
in  its  rigidity,  of  the  stuporous  patient,  some  theatrical  pose,  some  ; 
meaningless  phrase  that  one  might  vainly  seek  to  detect  in  the  j! 
course  of  melancholia,  are  all  extremely  valuable  aids  in  the  diag-  | 
nosis,  which  will  be  still  further  facilitated  by  the  history  of  tire  ! 
case,  from  which  it  will  be  made  evident  that  the  disease  had  an 
acute  or  insidious  hallucinatory  commencement,  with  strange,  j 
unusual  conduct  and  incoherence.  1 

We  have  already  spoken  of  the  difference  between  hallucinatory  | 
paranoia,  which,  after  all,  is  only  a sensory  insanity,  and  the  | 
genuine  primary  paranoia,  which  is  of  emotive-intellectual  origin,  | 
and  may  or  may  not  be  associated  with  secondary  hallucinations.  ! 
There  is  another  distinction,  how^ever,  between  acute  sensory  ■ 
insanity  and  acute  paranoia,  affections  which,  I hold,  should  be 


737 


SENSORY  INSANITY 

clearly  differentiated.  Whilst  in  acute  sensory  insanity  there  is 
a tumult  of  hallucinations  and  illusions,  in  acute  paranoia  (which 
many  authorities  have  confused  with  sensory  insanity)  we  have, 
on  the  contrary,  to  deal  with  only  a delirious  and  illusory  interpre- 
tation of  objects,  persons,  and  actual  facts,  without  hallucinations. 
In  this  case  the  disturbance  is  an  acute  non-hallucinatory  primary 
delirium,  which  at  most  is  sustained  by  illusions,  or  rather  by  false 
illusional  judgments  of  objects  and  persons  perceived  in  the  usual 
way  ; motor  super-excitement  and  loquacity  are  present  at  the 
same  time.  One  patient  under  my  care  used  to  look  at  me  during 
my  visit,  and  perceived  all  the  particulars  of  my  person,  yet  he 
maintained  that  my  features  and  my  clothing  masked  the  person 
of  a priest  who  had  taken  to  persecuting  him,  and  who  employed 
the  most  diabolic  means  to  do  him  injury.  He  made  similar  false 
judgments  regarding  everyone,  and  similar  illusory  interpretation 
of  all  objects  that  came  before  him,  including  food  and  drink,  so 
that  he  was  extremely  agitated  and  loquacious  about  one  group 
of  ideas,  amongst  which  one  sought  in  vain  for  a true  hallucinatory 
product. 

The  history  of  the  illness  enables  us  to  distinguish  the  genesis 
and  the  nature  of  certain  hallucinatory  deliria,  such  as  those  pro- 
duced by  intoxications,  amongst  the  latter  being  especially  the 
alcoholic  and  the  epileptic  and  hysterical  forms.  From  acute 
delirium  we  distinguish  sensory  insanity  only  by  the  extreme 
intensity  of  the  delirium  and  the  agitation,  and  by  all  the  serious 
phenomena  of  a true  acute  intoxication.  It  is  not  to  be  forgotten, 
however,  that  in  many  cases  acute  sensory  insanity  is  accom- 
panied by  fever,  and  in  these  the  bacterioscopic  examination  of  the 
blood  is  of  the  highest  value,  inasmuch  as  the  presence  of  a bacillus, 
so  far  as  our  actual  knowledge  goes,  favours  acute  delirium. 


Prognosis.—Acute  sensory  insanity  is  a serious  disease,  for  it 
sometimes  jeopardizes  life.  The  chronic  form  is  not  equally 
dangerous,  but  recovery  from  it  is  much  less  frequent.  In  my 
opinion  the  prognostic  views  of  Fritsch  and  of  Krafft-Ebing  are 
too  optimistic.  The  latter  claims  70  per  cent,  of  recoveiies.  I 
think  this  proportion  exaggerated,  whilst  those  of  Meynert  (44-5 

per  cent.)  and  of  Ziehen  (40  per  cent.)  seem  to  me  to  be  more 
exact. 

I agree  with  the  reserve  expressed  by  Seglas  and  Chaslin.  Of 
thirty  cases  thoroughly  studied  in  my  clinique,  twelve  recovered ; 
the  others  almost  all  ended  in  consecutive  dementia  (dementia 
pr?ecox  ?),  and  one  or  two  in  systematized  delirium  (paranoid 
sensory  insanity). 

The  percentages  of  deaths  (8  per  cent,  and  6 per  cent,  with 
-leynert,  28  per  cent,  with  Ziehen)  I believe  to  be  due  in  great 
measure  to  acute  delirium  (bacillary),  which  is  a disease  by  itself, 

47 


738 


PSYCHIATRY 


and  one  which,  judging  from  our  present  knowledge,  should  not  be 
confounded  with  sensory  insanity. 


Treatment.  — infective  nature  of  acute  sensory  insanity 
compels  us  to  combat  the  disease  with  due  regard  to  its  etiology. 
Here,  again,  however,  we  mxust  remember  that  if  micro-organisms 
or  toxines  are  a cause,  they  exert  their  action  only  on  individuals 
strongly  predisposed  by  heredity. 

From  this  point  of  view,  the  clinician  meets  with  difficulties  in 
the  prophylaxis,  which  is  the  same  as  in  the  mental  affections  in 
general,  and  need  not  be  discussed  here. 

Some  therapeutic  means  are  indicated  in  the  majority  of  cases 
either  of  the  acute  psychosis  or  of  any  of  the  clinical  varieties  derived 
from  it.  These  are  isolation,  with  the  object  of  removing  the 
patient  as  far  as  possible  from  the  stimuli  of  the  external  world,  and 
careful  dieting,  which,  on  the  one  hand,  should  produce  the  least 
possible  toxine,  and,  on  the  other,  should  make  good,  provided 
always  the  condition  of  the  stomach  allows  it,  the  deficit  produced 
by  tire  organic  consumption  of  these  patients. 

Hypodermic  injections  of  bichloride  of  quinine  are  useful  when 
the  disease  is  running  a febrile  course.  It  is  a good  rule  to  eliminate 
the  exciting  action  of  intestinal  intoxications  by  means  of  purga- 
tives, salol,  and  intestinal  lavage.  Blood-letting  in  very  robust 
individuals,  or  the  application  of  leeches  to  the  mastoid  processes, 
have  in  some  instances  given  me  good  results  ; but  I have  prescribed 
them  only  in  the  case  of  strong  patients.  Baths  in  the  acute  stage 
have  been  of  little  or  no  service.  Injections  of  morphine  hydro- 
chloride were  in  most  instances  useful  ; not  so,  however,  hyoscya- 
mine  or  hyoscine  or  duboisine  hypodermically.  These  are  dangerous 
drugs,  often  causing  unforeseen  results,  however  cautiously  em- 
ployed, especially  in  very  weak  persons.  Rest  in  bed,  recommended 
by  Neisser  and  Chaslin,  is  advantageous.  The  routine  prescrip- 
tion of  the  bromides  is  sometimes  useful.  If  morphine  is  not  success- 
ful as  a hypnotic,  I prefer  sulphonal  or  chloralamide. 

In  the  acute  stage,  at  the  very  commencement  I have  found 
nothing  more  useful  than  lavage  of  the  tissues  by  means  of  plentiful 
hypodermic  transfusions.  After  the  first  days  of  the  illness  this 
treatment  in  the  majority  of  cases  loses  its  efficacy. 

Once  the  acute  hallucinatory  period  is  past,  mild  hydrotherapy 
by  the  method  of  Ferno  or  that  of  Dagonet,  tonics  such  as  arsenu.-, 
open  air,  and  good  nourishment,  are  the  best  therapeutic  aids. 

1 have  derived  no  advantageous  results  of  any  consequence  fiom  | 
blisters  on  the  head  or  neck. 

One  remedy  not  to  be  neglected  in  the  treatment  of  stupor, 
when  the  hallucinations  have  ceased,  is  electricity  in  the  form  o 
galvanization  of  the  head,  with  2 to  4 milliamperes,  and  geneia 
faradization. 


SENSORY  INSANITY 


739 


The  moral  treatment  suggested  by  Sauze,  with  the  very  proper 
restrictions  indicated  by  Seglas,  are  of  possible  utility  only  in  a 
period  of  decline  of  the  illness,  and  especially  during  convalescence. 

There  are  many  grave  conditions  that  may  arise  unexpectedly 
in  the  acute  phase  of  the  illness,  and  call  for  medical  intervention. 
Amongst  the  chief  of  these  is  collapse,  in  which  case  ether,  camphor, 
and  quinine  have  enabled  the  physician  to  avert  an  almost  imminent 
disaster. 


47—2 


CHAPTER  XVII 
MENTAL  CONFUSION 

I HAVE  already  expressed  my  opinion  with  regard  to  mental  con- 
fusion. It  is  almxost  never  a disease  in  itself  ; it  is  a secondary 
symptom.  Most  frequently  it  is  sensory  disorders  that  give  rise 
to  the  confusion,  dissociating  the  psychic  products  of  high  synthetic 
value,  and  breaking  the  logical  associations  of  thought  and  action. 
They  suppress  the  power  of  the  higher  centres  (centres  of  psychic 
synthesis,  evocative  and  regulative),  and  this  gives  rise  to  the 
dissociation,  the  incoherence,  the  illogical  impulsions  of  acute 
dementia,  or  the  secondary  paranoid  formations  of  low  intellectual 
value. 

Nevertheless,  I do  not  feel  warranted  in  absolutely  denying  that 
mental  confusion  may  sometimes  be  primary,  and  run  its  course  for 
some  time  at  least  without  hallucinations.  Still,  this  must  be  a 
somewhat  rare  occurrence,  and  even  then  we  cannot  wholly  exclude 
the  possibility  of  error  arising  from  the  difficult  nature  of  the 
inquiry. 

The  disease  is  ushered  in  with  all  the  characteristics  of  neuras- 
thenia, lowering  of  the  perceptive  capacity,  diminished  rapidity  in 
the  formation  of  the  psychic  syntheses,  slowness  of  the  psychic 
processes,  facile  and  frequent  interruptions  in  the  course  of  the 
ideas,  memory  neither  ready  nor  faithful,  but  often  illusory,  a great 
difficulty  in  evoking  names,  confusion  of  things  real  with  things 
dreamt  of,  incapacity  of  attention,  ready  exhaustion,  frequent  dis- 
tractions, indifference,  lack  of  stable  objectives,  ready  changes  of 
humour,  alternations  of  pessimism  and  hilarity,  great  affective  ex- 
citability, phases  of  blanks  of  consciousness,  impulses  due  to  the 
insurrection  of  isolated  and  illogical  desires,  strange  actions,  eccen- 
tricity, and  sometimes  fleeting  delirious  conceptions  alternating 
with  the  consciousness  of  the  illness  and  with  melancholic  states. 
Hypochondriacal  features  are  almost  never  wanting. 

This  state  may  proceed  in  one  of  two  directions — either  it  lasts 
for  some  time,  with  alternations  of  improvement  and  aggravation, 
as  a grave  form  of  neurasthenia,  unaccompanied  by  sensory  dis- 

740 


MENTAL  CONFUSION 


741 


orders,  and  with  prevailingly  hypochondriacal  content  ; or  the 
hallucinations  occur  later,  and  the  malady  assumes  all  the  charac- 
teristics of  acute  dementia  or  amentia. 

It  is  most  frequent  in  women  who  have  had  many  pregnancies 
and  protracted  lactations  within  a brief  period,  and  in  predisposed 
youths  who  rapidly  ruin  their  constitutions  by  unrestrained 
onanism  and  school  tasks. 

Certain  varieties  of  polyneuritic  psychosis  the  development 
of  which  is  characterized  by  dysorientation,  amnesias,  and  more 
rarely  by  hallucinations  (Korsakoff,  Colella,  Esposito),  might  be 
included  in  this  chapter. 

Prognosis.— The  prognosis  is  rather  favourable.  The  few  cases 
I have  observed  of  those  not  complicated  by  evident  sensory  dis- 
orders ended  in  recovery. 


Therapy.— Uentsl  repose,  cessation  of  lactation,  removal  to  the 
country,  methodical  muscular  exercise,  disinfection  of  the  intestines 
with  ichthyol,  good  nourishment,  hydrotherapy,  electrotherapy  in 
the  form  of  general  faradization,  and  galvanization  of  the  head,  are 
the  best  therapeutic  aids,  and  these  may  be  advantageously  com- 
bined with  all  those  pharmaceutical  products  of  high  repute — iron, 
glycero-phosphates,  phosphorus,  arsenic— in  the  most  varied  forms. ' 


CHAPTER  XVIII 
ACUTE  PARANOIA 

W HILST  in  primary  chronic  paranoia  the  delirium  or  the  hallucina- 
tions arise  from  the  psychic  constitution  of  the  individual,  whose 
defect  is  apparent  in  the  exalted  emotivity,  in  the  direction  of  sus- 
picion and  vanity,  the  intellect  being  often  weak,  very  rarely  well  | 
developed,  in  acute  paranoia  the  onset  of  the  disease  differs  in  no  ; 
\\a,y  from  the  mode  of  commencement  of  all  the  other  diseases  of  ’* 
this  group  in  such  predisposed  persons  as  present  none  of  the 
features  characteristic  of  the  first  group.  < 

In  chronic  paranoia  the  disease  develops  insidiously,  the  patient  '• 
remaining  in  the  vague  borderland  between  sanity  and  insanity,  ! 
and  it  is  only  after  a longer  or  shorter  time,  in  some  instances  very  ' 
long,  that  the  disease  manifests  itself  clearly.  In  the  acute  form, 
on  the  contrary,  the  malady  arises  quite  unexpectedly  when  the 
mental  vigour  is  at  its  acme. 

As  in  primary  paranoia,  it  assumes  two  forms — the  delirious  ' 
and  the  hallucinatory.  The  latter  is  much  the  more  frequent.  The  ' 
patient,  after  a period  of  malaise  lasting  several  days,  oi  during  t 
convalescence  from  an  acute  infective  disease  (influenza,  small-pox,  ■! 
typhus,  etc.),  shows  himself  perturbed  and  preoccupied,  suffers  || 
from  severe  headache,  is  irritable,  suspicious,  or  placid  and  mystic 
in  his  demeanour. 

Sleep  is  disturbed  by  dreams  which  extend  their  influence  into 
the  waking  moments. 

Hallucinations  put  in  an  appearance,  and,  as  a rule,  they  are 
auditory  and  tactile.  The  patient  hears  abusive  voices,  threats, 
oaths,  intimations  addressed  to  him  from  the  walls  and  ceiling,  or 
from  the  public  highway.  He  is  agitated  and  teriified,  seeks  to 
make  his  escape,  feels  as  though  insects  were  swarming  over  him  j 
and  worms  crawling  over  his  skin,  or  as  though  drops  of  cold  or  , 
warm  watei  or  caustic  substances  were  made  to  fall  on  his  head.  ^ 
W'hen  he  can  no  longer  endure  these  torments,  he  tries  to  escape 
from  them — it  may  be  by  throwing  himself  from  the  window,  or  by 
seizing  a gun  and  bring  at  the  ceiling  of  his  room,  whence  come  the 
tormenting  voices. 


742 


ACUTE  PARANOIA 


743 


Distressed,  terrified,  irritable,  sleepless,  threatening,  impulsive, 
extremely  suspicious,  these  patients  are  an  imminent  danger  to 
themselves  and  those  around  them. 

There  are  often  kinaesthetic  paraesthesias  in  the  abdomen,  or 
gustatory  sensations  that  excite  false  ideas  of  poisoning.  The  food 
has  a bad  taste,  and  whenever  they  eat  anything,  no  matter  what, 
their  abdominal  sufferings  are  increased.  Every  attempt  to  eat 
furnishes  fresh  proof  of  the  treachery  of  hidden  enemies.  ‘ They 
wish  to  get  rid  of  him.’  For  this  reason  these  paranoiacs  refuse  food . 
or  appease  their  hunger  with  fruit  and  eggs,  or  with  something 
that  they  go  out  and  purchase  for  themselves,  and  these  they  pre- 
pare with  unusual  caution.  Cook,  mother,  sisters,  wife,  and  family 
are  all  suspected  alike. 

Such  a paranoiac,  feeling  himself  threatened  and  his  very  exist- 
ence jeopardized,  becomes  gloomy,  irritable,  intractable,  threaten- 
ing, and  impulsive.  ^ The  tongue  is  dry  and  coated,  the  breath  often 
acetonic.  The  fasting  or  the  scanty  and  unsuitable  food  aggravates 
this  state  of  affairs.  Temperature  is  some  decimals  higher  than 
usual ; nutrition  rapidly  fails. 

Sometimes  acute  paranoic  delirium  is  of  mystic  content.  An 
example  will  prove  of  more  service  than  any  description. 

Observation  XXXVI. — A woman,  whose  health  had  been  reduced 
by  repeated  parturitions  and  lactations  and  still  further  undermined  by 
an  attack  of  influenza,  dreamt  one  night  that  she  saw  the  Madonna  at 
the  foot  of  her  bed.  In  the  morning  she  awoke  deeply  impressed  by  the 
vision  that  had  appeared  to  her  in  her  dream,  and  sought  to  put  some 
construction  upon  it.  She  was  concentrated,  abstracted,  preoccupied, 
ate  little,  and  was  more  than  usually  irritable.  At  night  she  had  a repe- 
tition of  the  vision,  and  was  awakened  by  the  vivid  impression  it  made 
upon  her,  but  the  vision  remained  before  her  even  with  her  eyes  open. 
The  delirium  now  became  distinctly  organized  : she  was  certainly  ‘ the 
chosen  of  the  Madonna.'  She  had  no  further  interest  in  her  husband, 
her  family,  and  her  domestic  duties  ; she  appeared  quite  indifferent  to 
all  mundane  affairs  ; she  prepared  no  food,  refused  to  occupy  herself  or 
to  eat.  She  began  to  be  loquacious,  speaking  the  mystic  language  of 
the  inspired  person  ; she  interpreted  a number  of  normal  impressions  in 
an  illusory  manner.  She  always  spoke  logically,  expressing  the  convic- 
tion that  she  was  the  chosen  of  the  Madonna  who  appeared  to  her,  and 
that  she  was  ‘ destined  for  the  glory  of  heaven.’ 

In  acute  non-hallucinatory  paranoia,  much  less  common,  we 
have  to  deal  not  with  hallucinations,  but  simply  with  an  illusory 
interpretation  of  real  things.  The  delirious  conceptions  are  formed 
acutely,  and  are  religious  or  persecutory  in  content.  In  this  case 
the  patient,  excited  and  loquacious,  recognises  objects  and  persons, 
naming  them  properly,  but  giving  them  a signification  that  emanates 
from  the  nature  of  the  delirious  ideas. 

In  the  person  of  the  doctor  he  sees  a messenger  of  God,  in  another 
person  a Jesuit  travestied;  everything  assumes  a mystic  or  hostile 


744 


PSYCHIATRY 


signification.  Suspicion  and  fear  of  danger,  nourished  by  preformed 
conceptions,  become  attached  to  almost  every  person  of  his  acquaint- 
ance, near  or  far.  Throughout  the  course  of  the  disease,  or  a good 
part  of  it,  hallucinations  are  absent. 

The  affection  may  last  for  several  weeks,  being  rarely  prolonged 
beyond  two  months,  whilst  the  hallucinatory  variety  usually  lasts 
much  longer,  and  sometimes  passes  into  a chronic  state. 

These  two  varieties  of  acute  paranoia  correspond  to  the  analogous 
varieties  of  chronic  paranoia  (vide  ante).  The  latter  is  characterized 
not  only  by  delirium,  with  or  without  hallucinations,  but  also  by 
an  anomalous  structure  of  the  mind,  which  sometimes  manifestly 
contains  the  germ  of  the  disease.  In  acute  paranoia,  however, 
there  nia}/  be  hereditary  predisposition  (cerebral  vulnerability), 
but  nothing  to  remind  us  of  the  paranoic  character.  The  paranoic 
form  assumed  by  the  mental  affection  is  the  first  revelation,  and  is  of 
an  accidental  nature. 

The  fact  that  both  varieties  develop  in  consequence  of  acute 
diseases,  such  as  small-pox,  influenza,  pneumonia,  typhus,  etc., 
must  lead  to  the  conviction  that  they  are  of  toxic  origin. 


The  therapy  does  not  differ  from  that  adopted  for  the  otlier  -i 
acute  psychoses  already  described  as  belonging  to  this  group.  '| 


CHAPTER  XIX 


LATE  PARANOIA 

A PSYCHO-XEUROiic  form  of  paranoia  has  been  clearly  distinguished, 
particularly  by  Amadeo  and  Seppilli  in  Italy.  Anyone  with  a wide 
practice  in  mental  aff'ections  may  observe  cases  confirming  the  dis- 
tinction made  by  these  two  alienists.  Cases  certainly  exist  of  men 
perfectly  sane,  intelligent,  industrious,  well  balanced,  who,  as  the 
result  of  intense  and  prolonged  labour,  mental  worries,  intestinal 
diseases,  or  other  conditions  that  bring  about  exhaustion,  assume 
a demeanour  that  reminds  us  of  the  developmental  paranoiacs, 
and  in  the  long  run,  when  the  conditions  remain  unimproved, 
develop  a paranoia  which  differs  in  no  way  from  chronic  paranoia 
except  as  regards  the  soil  of  development. 

As  a rule,  it  is  persecutory  in  form  ; I have  not  observed  any 
case  of  the  expansive  form.  It  is  preceded  by  a longer  or  shorter 
period  of  suspicion,  irritability,  and  preoccupation.  The  patient 
has  a fear  of  becoming  insane,  and  keeps  himself  apart.  This  state 
is  generally  associated  with  abdominal  pains,  a feeling  of  palpita- 
tion, severe  headache,  or  unusual  sensations  in  the  head,  sometimes 
with  true  hypochondriasis,  with  allegorical  interpretations  of  the 
altered  kinaesthetic  sensations,  and  broken  and  unrefreshing  sleep. 
After  a period  of  such  sufferings,  which  alter  the  original  character 
of  the  patient,  hallucinations  commence,  and  these  are  generally 
kinaesthetic  or  persecutory  in  content. 

In  the  first  case  a progressive  hypochondriacal  delirium  is  set 
up,  with  a tendency  to  systematization  and  with  allegorical  inter- 
pretation of  a persecutory  nature,  leading  the  patient  to  assume  a 
hostile  attitude.  Such  delirium  as  this  rarely  reaches  the  grade 
or  assumes  the  characteristics  of  delirium  of  persecution.  It  has 
been  described  by  some  authors  as  hypochondriacal  paranoia,  by 
others  as  neurasthenic  paranoia,  or  as  hypochondriacal  melancholia, 
coinciding  with  the  climacteric  period,  on  which  account  it  has  been 
regarded  as  one  of  the  insanities  of  the  presenile  period. 

In  the  other  variety  of  this  paranoia  hallucinations  are  not 
slow  to  present  themselves.  They  may  be  auditory  or  olfactory, 

745 


746 


PSYCHIATRY 


and  more  especially  gustatory  and  kinaesthetic,  with  a rapid  and 
extensive  development  of  deliria  of  persecution,,  varying  in  content 
according  to  the  nature  of  the  hallucinations.  That  of  poisoning 
is  frequent.  Up  to  this  point  the  malady  assumes  all  the  charac- 
teristics of  chronic  paranoia. 

The  sole  difference  lies  in  the  late  and  occasional  genesis  of  such 
a paranoia  on  an  acquired  neurasthenic  basis,  and  in  the  possibility 
of  recovery  under  favourable  conditions  for  treatment  ere  the 
malady  has  attained  its  maximum  development. 


CHAPTER  XX 

NEURASTHENIC  INSANITY 

In  the  chapter  on  neurasthenia  I have  described,  as  far  as  possible 
within  the  limits  of  this  work,  the  phenomena  of  some  neurasthenic 
psychopathic  forms.  It  is  superfluous  to  add  here  what  we  have 
already  learned  in  the  case  of  paranoia — that,  as  opposed  to  inherited 
neurasthenia,  there  exists,  and  is  very  frequent,  acquired  neuras- 
thenia, which  may  be  attributed  to  malnutrition  of  the  nervous 
system  or  to  endogenous  or  exogenous  intoxications.  Here  we 
must  speak  more  especially  of  the  psychoses  that  develop  on  a 
neurasthenic  basis,  in  so  far  as  they  present  some  differential  charac- 
teristics permitting  their  recognition  and  distinction  from  the  more 
genuine  psychopathies.  We  know  that  the  neurastheniac  generally 
has  a tendency  to  the  melancholic  bent  of  mind.  He  is  undecided, 
timid,  perplexed,  preoccupied.  He  may  exhibit  phenomena  of 
anguish  and  a fearful,  sometimes  obsessive,  tendency  to  suicide ; 
but  neither  the  anguish  nor  the  psychic  arrest,  nor  even  the  lack 
of  confidence,  reaches  the  degree  usually  observed  in  melancholia. 
The  organic  sensations  that  attract  the  attention  of  the  neuras- 
theniac, ever  altering  and  shifting,  open  the  way,  not  only  to  emotive 
states  concerning  the  fate  of  his  health  and  the  future  of  himself 
and  his  family,  but  also  to  true  delirious  formations  regarding  the 
state  of  his  different  organs  and  his  entire  organism,  which  he 
believes  to  be  closely  threatened.  The  neurastheniac,  however,  is 
readily  distracted.  He  may  have  hours  of  happiness,  and  he  seeks 
to  drown  his  sorrows  in  some  form  of  gaiety,  in  this  respect  differing 
from  the  melancholiac.  The  neurastheniac  lacks  that  stability  of 
the  afflictive  tone  of  mind  characteristic  of  the  melancholiac,  and 
to  the  doctor  and  his  relatives  he  represents  in  vivid  colours  and  in 
a somewhat  dramatic  manner  more  than  he  really  feels,  and  whilst 
recounting  his  afflictions  he  allows  to  leak  out  tlie  strong  hope  he 
has  of  recovering,  a hope  which  unfortunately  is  absent  in  the  true 
melancholiac. 

Whilst,  however,  in  many  cases  such  a state  of  affairs  amelio- 
rates for  a longer  or  shorter  time,  either  to  relapse  to  its  former  state 

747 


74« 


PSYCHIATRY 


or  to  maintain  its  advance  towards  recovery,  it  not  infrequently  i 
happens  that  the  malady  becomes  aggravated  and  slowly  assumes 
all  the  features  of  hypochondriacal  melancholia. 

The  differential  diagnosis  in  these  cases  is  possible  only  in  the 
distinctly  neurasthenic  period,  which  may  last  for  a verv  long 
time. 

The  psychopathic  figure,  then,  that  neurasthenia  very  commonly 
assumes  is  that  of  hypochondriacal  psychosis,  which  may  be  con- 
founded witn  sensory  insanity  and  hypochondriacal  paranoia.  The 
diagnosis  is  important,  for  whilst  the  last-named  disease  offers  verv  I 
little  hope  of  recovery,  neurasthenic  hypochondriasis  is  often  fol-  . 
lowed  by  a complete  cure,  and  sensory  insanity  may  assume  the 
figure  of  hypochondriacal  acute  dementia  (according  to  others, 
dementia  praecox).  The  distinction  is  founded  on  the  following 
facts  : (i)  In  h^/pochondriacal  paranoia  there  is  a prevalence  of  the 
hypochondriacal  delirious  ideas  over  the  organic  sensations  and  | 
affective  states  of  mind,  whilst  in  neurasthenia  it  is  the  anomalous  : 
sensations  (paraesthesias)  with  the  relative  affective  states  that 
predominate ; and  whilst  the  neurastheniac  judges  his  sensations  in 
his  own  manner,  the  paranoiac  enters  into  the  field  of  false,  some- 
times  paradoxical,  judgments— true  delirious  ideas  with  feeble  ; 
affective  accompaniments ; (2)  in  the  paranoiac  the  delirious  ideas  '' 
are  accompanied  at  an  early  stage  by  hallucinations  and  illusions, 
which  sometimes  remain  kinaesthetic  in  nature,  but,  on  the  other  , 
hand,  are  frequently  accompanied  by  other  hallucinations,  gusta- 
tory and  auditory,  that  provoke  fresh  delirious  ideas  of  a persecu- 
tory content,  and  referring  especially  to  poisoning,  so  that  at  . 
bottom  the  paranoiac  is  a suspicious  individual,  who  sometimes  , 
attributes  to  the  malevolence  of  others  what  he  thinks  and  judges  i 
of  his  own  health.  The  neurastheniac  is  more  concentric  in  his 
interpretation.  The  paranoiac  tends  to  externalize — that  is  to  say, 
to  attribute  to  others  the  cause  of  his  supposed  afflictions.  As  ’^1 
regards  hypochondriacal  sensory  insanit}^  we  have  already  indi- 
cated its  characteristics. 

It  is  to  be  borne  in  mind  that  intermediate  forms  exist  which 
can  with  difficulty  be  classified  with  one  or  other  of  the  affections  ' 
mentioned.  In  these  cases  the  prognosis  is  much  more  difficult, 
and  must  be  made  with  great  reserve. 

['  ^'1  It  is  unnecessary  in  this  chapter  to  add  anything  to  what  I have 
already  expressed  in  detail  with  regard  to  fixed  ideas  and  obsessions, 
which  represent  very  frequent,  and  I might  almost  say  characteristic, 
syndromes  of  neurasthenia. 

There  is  one  form  of  neurasthenia  that  passes  slowly  and  in- 
sidiously into  paralytic  dementia. 

In  the  chapter  dealing  with  this  encephalopathy  I shall  treat 
in  greater  detail  of  those  varieties  of  this  affection. 

A great  depression  of  the  mental  tone,  a marked  slowness  and  j 


NEURASTHENIC  INSANITY 


749 


dulness  of  the  psychic  processes,  with  tremors,  inequality  or  fixity 
of  the  pupils,  inequality  and  especially  absence  of  the  patellar 
reflex,  are  sure  indications  of  progressive  paralysis,  even  when 
neither  the  characteristic  alterations  of  speech  nor  notable  mental 
defects  are  present. 

From  hysteria  we  can  distinguish  neurasthenia  only  by  the 
presence  in  the  former  of  hysterical  stigmata,  of  which  I have 
already  said  sufficient  in  the  chapter  on  hysterical  insanity. 

The  prognosis  is  much  less  grave  in  acquired  than  in  develop- 
mental constitutional  neurasthenia. 

For  the  therapy  I refer  the  reader  to  what  has  been  set  forth  in 
the  chapter  on  neurasthenia. 


CHAPTER  XXI 


! 


CHOREIC  INSANITY 

Chorea,  of  whatever  form,  is  always  accompanied  by  mental  dis- 
turbances. From  the  anatomo-pathological  point  of  view,  we  must 
draw  a distinction  between  the  mental  disturbances  accompanying 
common  or  Sydenham’s  chorea  and  those  that  are  among  the  most 
classic  manifestations  of  the  chronic  chorea  of  Huntingdon.  In| 
this  chapter  we  must  limit  ourselves  to  the  mental  disorders  accom-i 
panying  ordinary  chorea  ; the  others,  having  a graver  anatomo- 
pathological  substratum  of  a progressive  nature  and  less  definite 
origin,  should  be  described  among  the  psychoses  of  the  third  group.' 

Since  the  observations  of  Naunyn  (1888),  who  found  a bacillus 
in  a fatal  case  of  chorea,  those  of  Hitzig  (1890),  who  discovered 
streptococci  in  two  cases,  and  of  Pianese  (1893),  who  found  a bacillus 
and  a diplococcus  in  a case  in  De  Renzi’s  clinique,  we  have  had 
continual  confirmation  of  the  hypothesis  that  the  ordinary  formj 
of  chorea  is  of  infective  or  toxic  origin,  and  that  the  pathogenic, 
agents,  direct  or  indirect,  exercise  their  action  on  the  nerve-elements 
of  the  cerebral  cortex,  and  possibly  also  on  the  lower  centres.  I 

The  constant  association  of  mental  disturbances  with  chorea,  and 
the  prompt  recovery  from  these,  along  with  the  disappearance  of  thej 
muscular  phenomena,  are  clear  indications  of  the  intimate  relation; 
that  exists  between  psychic  and  somatic  phenomena  in  a large! 
number  of  diseases  of  the  nervous  system.  The  lesions  are  limited: 
to  those  described  under  the  term  ‘ fever  change  ’ — that  is  to  say,! 
to  alterations  in  the  form  of  chromatolysis,  now  universally  admitted 
to  be  toxic  in  nature. 

In  this  treatise  I am  compelled  to  confine  myself  to  the  descrip- 
tion of  the  psychic  phenomena  of  ordinary  chorea,  without  entering! 
into  all  the  details  regarding  the  doctrine  of  the  genesis  and  nature  | 
of  the  disease.  The  subject  is  very  fuUy  dealt  with  in  all  treatises; 
of  neuropathology,  and  it  is  unnecessary  here  to  enter  into  details.  ! 

The  choreic  subject,  we  have  said,  is  alwa^^s  mentally  affected.! 
Even  at  the  commencement  of  the  disease,  when  the  choreic  move- 
ments are  mistaken  for  childish  restlessness  by  the  school-teachers 
and  members  of  the  family,  the  character  is  already  markedly  altered.  | 

750 


CHOREIC  INSANITY 


751 


We  have  geuerally  to  deal  with  children  and  adolescents,  much  more 
rarely  with  young  adults  ; it  is  more  frequent  in  females.  They  show 
themselves  abstracted,  inattentive,  and  indifferent.  They  lose  their 
accustomed  serenity  and  their  perspicacity  in  perceiving  and 
judging  of  what  goes  on  around  them  in  the  family,  in  the  school, 
and  amongst  companions.  They  lose  their  customary  presence  of 
mind  and  their  high  spirits  ; they  become  more  captious,  irritable, 
gloomy,  impulsive  ; they  become  less  courageous  than  usual  ; they 
show  themselves  very  fearful,  and  submit  without  reaction  to  the 
bullying,  the  jeers,  and  tricks  of  their  companions.  They  pay  no 
attention  to  their  lessons,  learn  nothing,  and  only  in  rare  instances 
are  capable  of  committing  tasks  to  memory. 

This  state  of  affairs  lays  them  open  to  unjust  punishments,  the 
morbid  state  being  mistaken  for  a wilful  negligence  of  their  duties, 
until  at  length  the  physician  points  out  the  true  nature  of  the  altera- 
tion that  has  taken  place  in  the  nature  and  aptitude  of  these  children. 

At  home  they  display  very  feeble  and  capricious  affective 
sentiments  towards  their  nearest  and  dearest  ; they  appear  indif- 
ferent when  they  do  not  show  direct  perversion  of  family  affection, 
in  caprices,  whims,  pretexts,  or  in  exalted  affectivity,  and  in  weeping’ 
laughter,  and  fear. 

When  the  disease  has  reached  its  full  development,  and  the 
muscular  agitation  is  very  pronounced,  the  mental  disturbances  are 
also  very  evident  ; they  rise  not  only  from  the  sphere  of  the  senti- 
ments and  of  the  will,  but  also  from  that  of  thought,  which  in  the 
first  stage  of  the  disease  does  not  seem  notably  affected.  The 
perceptions  are  fleeting,  incomplete,  and  interrupted  ; the  attention 
is  defective,  or  there  is  entire  absence  of  the  ordinary  process  for 
judgment  in  accordance  with  the  associative  laws,  taking  into 
account  the  nature  and  ideative  content  of  the  various  subjects. 

The  associative  processes  are  often  interrupted. 

Every  discharge  of  nerve-waves  giving  rise  to  illogical  and  in- 
determinate muscular  contractions  induces  either  weakening  or 
direct  suspension  of  the  tensions  in  the  associative  paths.  In  this 
case  the  phrase  is  not  completed,  the  judgment  not  expressed,  a 
discourse  cannot  be  logically  maintained.  The  choreic  individual 
loses  the  thread  of  his  thought ; his  speech  is  interrupted  and  jerky, 
reminding  one  of  a keyboard  no  longer  touched  by  the  artiste  who 
draws  from  it  sweetly-flowing  melodies,  but  by  one  who  has  little 
or  no  musical  notions. 

In  addition  to  the  continual  discharge  of  nerve-waves  into  the 
muscular  fields,  diminishing  the  potential  of  various  cerebral  points, 
there  is  also  the  influence  of  the  muscular  attitudes  upon  the 
emotive  state  and  the  course  of  the  patient’s  thoughts. 

W hen  the  physiognomy  of  the  choreic  sufferer  fleetingly  assumes 
the  muscular  attitude  of  laughter,  hatred,  fear,  sorrow,  or  anger,  rudi- 
ments of  the  corresponding  emotions  pass  through  his  mind,  in 


752 


PSYCHIATRY 


accordance  with  the  well-known  law  of  the  associations,  and  the 
reciprocal  influence  of  emotion  upon  the  muscular  and  physiognomic 
attitudes.  The  occurrence  of  these  rudimentary  emotive  states  is 
not  without  its  influence  on  the  course  of  thought,  and  therefore  there 
is  not  infrequent  in  the  well-developed  malady  a more  or  less  marked 
degree  of  mental  confusion,  and  sometimes  even  incapacity  to 
express  any  thought  whatsoever.  Mutism  often  prevails. 

In  the  gravest  forms  hallucinations  may  arise,  complicating  the 
condition,  and  giving  rise  to  disorder  in  the  intellectual  processes, 
as  is  their  wont,  and  as  we  have  already  seen  in  dealing  with  sensory 
insanity.  They  are  less  frequent,  however,  than  is  held  by  Marce 
and  others  ; they  are  absent  in  the  gravest  forms  of  chorea.  They 
are  generally  mournful  spectacles  (hell,  battles,  beasts,  etc.)  that 
succeed  one  another  as  in  a kaleidoscope,  giving  rise  to  confusion 
and  agitation. 

At  a more  advanced  stage  of  the  disease  it  is  no  rare  thing  to  have  | 
a true  psycho-motor  agitation  of  hallucinatory  origin  complicating  i 
the  muscular  agitation  proper  to  the  chorea.  ,| 

In  this  case  the  unfortunate  patient  lies  in  bed  (night  and  day)  ' 
in  a continual  state  of  agitation  of  the  most  incoherent  nature,  : 
exposing  himself  to  the  danger  of  bruises  in  every  part  of  his  ; 
body  ; the  temperature  rises  above  the  normal,  the  face  is  con-  I 
gested,  the  eyes  injected,  the  tongue  dry  and  coated,  the  breath  ^ 
foul,  the  bowels  constipated. 

Diagnosis. — The  diagnosis  presents  no  difficulty  ; the  muscular 
phenomena  of  chorea  are  sufficient  in  themselves  to  indicate  clearly 
the  nature  of  the  mental  disturbances.  " ' 

The  duration  is  from  several  weeks  to  three  months  or  so.  The  i 
usual  termination  is  recovery.  In  no  case  have  I seen  a fatal  result.  \ 
When,  however,  the  malady  reaches  the  extreme  degrees  above  de-  ' 
scribed,  with  pronounced  muscular  and  psychic  agitation,  we  may  have  <1 
cause  to  fear  collapse,  or  a syndrome  of  meningitis  or  encephalitis. 

Therapy. — In  the  mild  forms  it  is  unnecessary  to  make  any 
special  provision  for  the  mental  disturbances  accompanying  chorea. 

It  is  sufficient  to  cure  the  latter. 

In  the  acute  and  severe  forms  it  is  sufficient  to  place  the  patient 
under  conditions  that  secure  him  from  the  possibility  of  blows  and 
injuries,  and  to  commence  as  soon  as  possible  a system  of  treatment  i 
similar  to  that  indicated  in  all  the  acute  toxic  and  infective  diseases,  | 
and  especially  abundant  hypodermic  transfusions,  and  lavage  of  I 
the  intestines  with  sterilized  water  or  water  containing  ichthyol.  ' 
Morphine,  antipyrine,  salicylate  of  soda,  chloral,  bromides,  applica-  | 
tion  of  cold  to  the  head,  may  be  indicated,  according  to  the  general 
conditions,  which  must  not  be  lost  sight  of  in  dealing  with  acute  ' 
cases,  which  vary  greatly  in  their  manifestations,  according  to  the  i 
constitution  of  the  patient.  | 


CHAPTER  XXII 


LUETIC  INSANITY 

A-differenxe  of  opinion  prevails  with  regard  to  the  frequency,  and 
even  the  genesis,  of  syphilitic  insanity.  Whilst  Berkeley  holds  it  to 
be  comparatively  frequent,  at  the  same  time  he  mentions  how 
markedly  he  is  at  variance  with  Clouston,  who,  amongst  3,000 
patients  in  the  Edinburgh  x\sylum,  found  only  16  cases  of  syphilitic 
insanity. 

My  experience  inclines  me  to  favour  Clouston’s  statistics  rather 
than  those  of  Mendel,  who,  in  122  cases  of  mania,  melancholia, 
hypochondriasis,  and  other  forms  of  insanity,  found  18  coinciding 
with  manifestations  of  secondary  syphilis,  and  10  with  phenomena 
of  tertiary  syphilis. 

Syphilis  acts  on  the  central  nervous  system  in  two  directions  : 

(a)  through  the  syphilitic  toxines  and  their  indirect  derivatives  ; 

(b)  through  lesions  of  the  bloodvessels  and  the  lymphatics  concerned 
in  the  nutrition  of  the  nerve-elements.  The  psychoses  that  commence 
soon  after  the  penetration  of  the  syphilitic  virus  into  the  organism 
are  in  most  instances  to  be  attributed  to  the  intoxication  and  those 
minute  cell-changes  which  we  suppose  to  occur,  although  we  are 
unable  to  demonstrate  them. 

The  syphilitic  infection  acts  like  all  other  infections  and  intoxica- 
tions (vide  Chapter  XII.),  giving  rise  to  the  most  diverse  forms  of 
psychopathies,  without  impressing  upon  them  any  particular  char- 
acteristics. Kowalewski  says  there  is  not  a single  psychosis  that 
cannot  be  caused  by  syphilis.  In  this  respect  the  syphilitic  virus 
does  not  differ  from  the  toxines  of  the  diplococci  or  the  streptococci, 
which  give  rise  indifferently  to  melancholia,  amentia,  acute  paranoia, 
etc.,  irrespective  of  the  nature  of  the  soil  of  development.  Many 
of  these  forms  differ  in  no  way  from  those  that  arise  in  non-syphilitic 
individuals.  We  have  generally  to  deal  with  persons  predisposed 
by  heredity,  in  whom  syphilis  is  merely  a determining  cause,  the 
mental  affection  assuming  the  same  form  in  them  as  in  the  non- 
syphilitic (Galiano,  Revue  de  Psychiatrie,  vol.  xi.). 

Forms,  however,  have  been  described  bearing  special  character- 

753  48 


754 


PSYCHIATRY 


istics,  and  developing,  as  a rule,  at  the  commencement  of  the  | 
disease,  before  the  secondary  manifestations  or  during  these  latter,  j 
They  are  forms  of  neurasthenia,  of  melancholia,  more  rarely  of  mania,  ' 
in  which  the  patient’s  mind  generally  reveals  a great  preoccupation : 
about  the  primary  disease  associated  with  his  present  condition. , 
The  neurasthenia  is  of  a prevailingly  hypochondriacal  form,  in  which 
the  various  manifestations  of  syphilis  are  interpreted  in  a manner 
pessimistic  in  the  highest  degree  ; in  the  melancholic  form  the  j 
prevailing  feature  is  delirium  of  culpability  and  auto-accusation 
as  well  as  of  sinfulness,  and  it  always  has  reference  to  the  fault  of 
having  contracted  the  primary  disease. 

The  maniacal  forms  are  not  pure  ; they  are  generally  of  a 
maniacal-depressive  variety.  The  disease  often  commences  with 
the  melancholic  phase,  in  which  the  mind  of  the  patient  is  oppressed 
by  the  thought  that  he  himself  has  been  the  cause  of  his  disease, 
which,  owing  to  its  gravity,  gives  rise  to  great  preoccupation, 
anguish,  accessions  of  desperation,  insomnia,  irritability,  ennui,  or 
tcedium  vitcB. 

When  this  state  has  lasted  several  weeks  or  even  months,  the 
maniacal  phase  breaks  out  almost  suddenly,  and  is  generally  of  a 
mild  type  (hypomania). 

Hallucinatory  insanity  must  in  most  instances  be  attributed  to; 
rather  severe  lesions  of  the  cortex,  and  especially  of  the  vessels. 
Simple  syphilitic  intoxication  hardly  ever  gives  rise  to  severe  sensory 
insanity  in  any  one  of  its  forms. 

It  is  true  that  Fournier  has  described  grave  forms  of  melancholia 
and  stupidity  associated  with  tertiary  syphilis,  and  that  Mickle  and 
others  have  maintained  that  these  forms  of  insanity  do  not  depend 
on  any  evident  lesions  in  the  brain,  although  these  may  be  found  m 
other  parts  of  the  body.  Such  cases,  however,  must  be  very  rarq 
when  we  consider  that  these  forms  are  but  seldom  followed  by 
complete  recovery,  whilst  they  very  often  leave  behind  them 
intellectual  defects  (secondary  dementia).  | 

Whether  epilepsy  may  be  attributable  to  simple  syphilitici 
intoxication  is  a matter  of  dispute.  i 

If  we  were  to  believe  all  that  is  written  by  authorities  who  holdj 
the  majority  of  late  epilepsies  to  be  of  syphilitic  origin,  we  shoulc 
have  to  conclude  that  such  epilepsies  depend  on  simple  intoxication  ! 
This  supposition,  however,  lacks  proof  ; yet  even  were  it  demon-i 
strated,  we  should  have  to  conclude  tha^-  syphilis  merely  raises  tht| 
curtain  that  conceals  an  inherited  epileptic  structure. 


CHAPTER  XXIII 


ACUTE  DELIRIUM 

Acute  delirium  might  be  regarded  as  an  intense  sensory  insanity. 
It  is  a grave  general  affection  of  the  cerebral  cortex,  with  predomi- 
nance of  hallucinations  and  a rapidly  increasing  dissolution  of  the 
psychic  personality  ; it  soon  reaches  its  height,  and  is  characterized 
by  intense  motor  agitation,  clouding  and  even  abolition  of  conscious- 
ness, muscular  contractions,  true  convulsive  attacks,  fever,  tendency 
to  collapse,  and  fatal  issue. 

The  old  and  vexed  question  as  to  whether  acute  delirium  is  a 
morbid  entity  or  a syndrome  occurring  as  an  episode  in  various 
morbid  states  still  remains  unsettled.  Yet  were  we  to  consider 
acute  delirium  as  an  expression  of  grave  intoxication,  we  should  have 
no  difficulty  in  conceiving  that  it  might  sometimes  be  an  illness  in 
Itself,  at  other  times  a complication  of  another  affection.  The 
difficulty  lies  in  defining  the  cause  of  acute  delirium — that  is  to  say, 
in  deciding  whether  it  is  always  a specific  infection  produced  by  a 
micro-organism,  or  if  various  pathogenic  agents  are  capable  of  giving 
rise  to  it.  The  problem  is  not  easy  of  solution,  for  the  diagnosis  of 
true  acute  delirium  is  difficult.  Between  acute  sensory  delirium 
(grave  sensory  insanity)  and  the  acute  delirium  that  presents  con- 
vulsive phenomena  at  an  advanced  stage,  there  is  a gradation  of 
intermediary  forms  that  makes  the  question  of  diagnosis  extremely 
difficult.  Fever,  intense  and  acute  psycho-motor  agitation,  and 
complete  hallucinatory  dysorientation,  are  phenomena  that  are 
observed  also  in  less  serious  varieties,  and  terminate  in  recovery. 

The  cases  referable  to  this  last  category  are  by  no  means 
rare  and  the  majority  of  them  certainly  belong  to  grave  sensory 
insanity. 

Calmeil  has  already  described  it  in  a few  words,  which  leave  no 
doubt  that  the  celebrated  French  alienist  recognised  its  nosological 
dignity,  as  did  also  Fiirstner,  Schiile,  Jensen,  Mendel,  Buchholtz. 

Symptomatology. — It  is  preceded  for  some  days  by  a feeling  of 
malaise,  anorexia,  general  prostration,  severe  headache,  painful 

755  48—2 


PSYCHIATRY 


• 756 


sensations  in  the  limbs,  great  psychic  irritability,  and  a dazed 
state.  Then  the  delirium  breaks  out,  generally  at  night,  with 
various  hallucinations  of  terrifying  content,  parsesthesias,  and  very 
keen  agitation. 

The  patient  manifests  an  inclination  to  run  away,  utters  confused 
words,  calls  out  from  terror,  show^s  general  agitation,  and  rushes 
about.  The  face  is  red  and  congested,  the  eyes  gleaming,  the 
muscles  in  constant  unrest.  This  state  of  agitation,  with  marked 
movements,  which  from  the  outset  is  accompanied  by  fever,  anorexia, 
constipation,  refusal  of  food,  and  mental  confusion,  always  hallu- 
cinatory in  content,  lasts  only  from  three  to  six  days,  after  wTich 
phenomena  of  depression  appear  on  the  scene.  In  this  second 
phase  of  the  disease  the  patient  is  less  agitated,  but  is  always  very 
confused,  even  more  so  than  in  the  former  phase.  He  speaks 
continually,  but  there  is  no  logical  connection  between  the  words 
and  the  phrases  to  which  he  gives  utterance.  These  are  all  hallu- 
cinatory in  content,  a mere  torrent  of  words,  badly  pronounced, 
sometimes  quite  inarticulate  or  partly  articulated  and  pronounced 
in  a rough  and  muffled  voice,  even  to  the  extent  of  complete  aphonia. 
From  time  to  time  he  attempts  to  get  out  of  bed,  opens  his  eyes  in  a 
frightened  manner,  or  reacts  in  irritation  against  the  persons 
attending  him,  only  to  fall  again  into  the  state  of  incoherent  and 
often  incomprehensible  logorrhoea,  broken  by  episodes  of  rather 
intense  agitation.  No  logical  connection  is  observed  in  his  mani- 
festations, not  even  a clearly  formulated  delirium  ; the  phenomenon 
of  verbigeration  is  frequent,  the  associations  arising  sometimes  onty 
by  alliteration.  Meanwhile,  the  patient  maintains  a hostile  atti- 
tude, and  refuses  his  food  ; the  mouth  becomes  parched,  the  lips 
covered  with  sordes,  the  tongue  dry,  the  breath  foetid. 

In  a third  phase  the  disease  is  even  more  aggravated.  The 
patient  lies  prostrate  in  bed,  wdth  his  eyes  half  closed  ; he  speaks 
unceasingly  in  a low  tone,  uttering  incomprehensible  w'ords,  his 
voice  being  now  much  w^eaker.  The  pulse  becomes  more  rapid 
and  small,  the  respirations  shallower  and  more  frequent ; the  cornea 
loses  its  lustre,  the  pupils  become  fixed  and  sometimes  unequal. 
The  patient  becomes  pale,  or  else  his  cheeks  are  coloured  a deep 
red.  The  nares  are  fuliginous,  the  hands  tremble  and  perform 
irregular  movements,  and  sometimes  there  are  convulsive  states, 
with  signs  of  opisthotonos.  The  skin  becomes  covered  wdth  per- 
spiration, wdiich  gradually  becomes  clamm}*,  and  phenomena  ot 
collapse  supeiw'ene,  terminating  in  death  at  the  end  of  the  second  or 


third  week. 

Throughout  the  course  of  the  disease  there  is  persistent  fe\er, 
and  the  temperature  in  tlie  axilla  ranges  from  384°  C.  to  40°  C., 
sometimes  even  41°  C.,  to  descend  below'  the  normal  on  the  supei- 
vention  of  the  phenomena  of  collapse.  The  pulse  often  increases 
to  140,  the  respirations  to  40  and  even  more. 


ACUTE  DELIRIUM 


757 


The  urine  is  scanty,  and  an  abundance  of  indican  has  been 
noticed  (Regis).  Albuminuria  and  even  peptonuria  is  frequent 
(Coppin),  and,  according  to  my  own  experiments,  as  well  as  those 
of  Buchholtz,  the  urine  is  toxic  in  a high  degree. 

We  cannot  agree  with  those  authorities  who  give  a less  gloomy 
description  of  this  disease,  and,  like  Schiile,  even  admit  a stuporous 
form,  or,  like  Anglade  in  the  treatise  of  Alberto  Bullet,  a maniacal 
variety,  for  both  forms  certainly  belong  to  grave  sensory  insanity. 

Pathological  Anatomy.- — -We  confine  ourselves  to  the  mention  of 
what  seems  most  assured.  At  the  autopsy  of  a patient  who  has 
died  from  acute  delirium  we  find  always  a marked  congestion  of 
the  meninges  and  of  the  brain,  infiltration  of  the  pia,  and  increase 
of  the  subarachnoid  fluid.  The  brain,  which  is  very  tense  and 
congested,  presents  cortical  and  also  subcortical  hsemorrhagic 
points.  The  whole  brain  is  darker  in  colour,  and  sometimes  oede- 
matous.  On  microscopic  examination,  in  addition  to  marked 
increase  of  the  capillary  network,  we  find  an  advanced  chroma- 
tolysis in  the  cerebral  cells  (Hoche,  Cristiani),  alteration  of  the 
cell-nucleus,  and  also  of  the  cell-parenchyma,  along  with  de- 
formity and  shrinking  of  many  nerve-cells,  disappearance  or  break- 
ing of  the  processes,  and  varicose  atrophy  of  the  nerve-prolonga- 
tions, noted  by  Cristiani  with  the  aid  of  Golgi’s  method  ; increase 
of  the  neuroglial  and  vascular  nuclei,  denied  by  Cristiani  but  ob- 
served by  Anglade  and  myself,  even  to  the  degree  of  neuroglial 
hyperplasia.  We  have  not  had  a recent  case  permitting  re-examina- 
tion of  the  subject  in  question  with  the  aid  of  the  new  methods 
adapted  for  the  demonstration  of  the  network  of  endocellular 
neuro-fibrillae,  which  are  the  essential  constituents  in  the  complex 
structure  of  the  nerve-cell.  To  resume,  the  marked  hyperaemia 
and  the  rapid  and  intense  degeneration  of  the  nerve-elements,  with 
vascular  and  neuroglial  alterations,  are  certain  proofs  that  what  we 
call  acute  delirium  is  a malady  quite  different  from  all  the  other 
psychopathic  forms  running  a long  course,  and  must  therefore 
depend  on  causes  and  circumstances  quite  apart  from  those  con- 
nected with  all  the  other  acute  psychopathies.  Leaving  aside  the 
other  anatomo-pathological  findings,  such  as  those  of  Futterer, 
Snell,  Holsti  (an  account  of  these  may  be  found  in  my  three  articles 
on  acute  delirium  published  in  the  Annali  di  Neurologia  in  1893, 
1894,  3-nd  1899),  we  can  certainly  accord  a very  high  value  to  the 
acute  alteration  of  the  kidneys,  corresponding  to  the  albuminuria, 
and  confirming  the  notion  that  the  clinical  form  described  is  the 
effect  of  a severe  intoxication. 

.Etiology. — On  the  real  nature  of  the  intoxication  hangs  the  keen 
discussion  aroused  by  the  bacteriological  researches  carried  out  in 
my  Clinique.  The  discovery  of  a particular  bacillus  first  described 


758 


PSYCHIATRY 


by  Piccinino  and  myself,  and  confirmed  by  some,  denied  by  others, 
has  led  to  an  unquestionably  happy  result,  inasmuch  as  the  majority 
of  those  who  have  repeated  the  investigations  (Rasori,  Ceni,  Pottes, 
Cabitto,  Alessi,  Cappelletti,  Kalzowski)  have  found  either  the 
same  bacillus  or  something  analogous,  or  other  micro-organisms, 
such  as  the  Staphylococcus  aureus,  diplococci,  streptococci,  etc.  ; 
A’hen  we  consider  that  the  bacterial  varieties  met  with  at  the  ' 
outset  in  other  acute  curable  forms  are  no  longer  found  in  the  | 
blood  of  the  patients,  once  the  first  phase  of  the  psychopathy  is 
past,  these  results  indicate  that  the  bacteria  are  related  in  some 
way,  directly  or  indirectly,  with  the  genesis  of  the  disease. 

The  problem  is  by  no  means  easy  of  solution,  but  we  can  hold 
it  erroneous  to  say  that  the  presence  of  these  micro-organisms  is 
casual  or  due  to  penetration  into  the  blood  in  the  period  preceding 
death.  These  two  objections  presented  by  Ceni  and  Cappelletti 
are  overruled  by  the  fact  that,  in  the  initial  phase  of  the  acute  grave 
psychopathies,  the  bacterial  finding  is  often  positive,  whilst  later 
it  is  almost  always  negative,  just  as  it  is  negative  when  the  disease 
ends  in  recovery.  It  is  also  a fact  that  in  acute  delirium  the  baciUus 
has  been  found  in  the  blood,  not  only  in  the  period  preceding 
death,  but  also  during  the  second  phase  of  the  disease,  several 
days  before  death. 

It  remains  to  be  shown  whether  such  micro-organisms  are  really 
pathogenic  or  aggravating  concomitants.  In  the  present  state  of 
our  knowledge  it  is  impossible  to  give  a decided  opinion.  In  our 
first  communication  we  did  not  affirm  that  the  particular  bacillus 
produces  the  particular  syndrome  of  acute  delirium,  as  we  have 
described  it,  distinguishing  it  from  the  other  analogous  forms,  ^^*e 
wished  to  establish  the  coexistence  of  two  facts — the  gravity  of  the 
disease  and  the  presence  of  the  bacillus  in  the  blood — which  justify 
the  supposition  of  a relation  between  them  : either  the  bacillary 
toxines  are  the  cause  of  the  symptomatic  complex,  or  the  primary 
intoxication  giving  rise  to  the  delirium  alters  the  organic  chemistry 
in  such  a way  as  to  render  possible  the  penetration  of  those  micro-  ; 
organisms  into  the  blood-stream.  For  the  reasons  already  ex-  | 
plained  in  the  chapter  dealing  generally  with  this  group,  I do  not  j 
exclude  the  possibility  of  the  existence  of  both  a bacillary  and 
coccal  form  of  acute  delirium,  the  former  being  perhaps  the  graver,  I 
the  latter  probably  falling  under  the  categoiy  of  acute  sensory  | 
delirium.  ' 

I here  give  a drawing  of  the  bacillus  studied  by  Piccinino  and 
myself  (Figs.  97  and  98). 


Prognosis. — The  prognosis  is  closely  related  to  the  diagnosis,  , 
which  is  always  a difficult  matter  as  regards  the  clinical  distinction  1 
of  the  bacillary  from  the  coccal  delirium,  except  with  the  help  of  i 
bacteriological  investigation. 


ACUTE  DELIRIUM 


759 


Fever  rising  above  39"^  C.,  rapid  prostration,  intense  confusion  and 
incoherence,  rigidity,  and  more  especially  inequality  of  the  pupils, 
irregular  tremors,  convulsive  phenomena,  and  dryness  of  the 
mucous  membranes,  all  bespeak  the  graver  form,  and  predict  a 
fatal  issue. 


Therapy. — Since  the  patients  are  now  sent  to  the  asylum  more 
promptly  at  the  outset  of  the  disease,  deaths  from  acute  delirium 
are  less  frequent  than  was  formerly  the  case.  In  fact,  although 
during  the  last  two  years  we  admitted  into  the  asylum  at  Naples 
several  patients  presenting  symptoms  of  acute  delirium,  in  no  case 
have  we  had  a fatal  issue.  The  method  of  treatment  employed  in 


\ 

\ 


\ 

* f 


//  s"7 
J f 


II  ^ 


^4 


I 


Figs.  97  and  98. — Bacilli  found  in  the  Blood  and  in  Cultures. 


these  cases  is  summed  up  in  intestinal  disinfection,  lavage  of  the 
tissues,  and  maintenance  of  good  cardiac  tone.  These  indications 
are  met  by  milk  diet  and  salol  internally,  by  plentiful  intestinal 
lavage  with  several  litres  of  water,  by  hypodermic  transfusion  of 
ardficial  serum,  from  500  to  1,200  grammes  at  a time,  hypodermic 
injections  of  bichloride  of  quinine,  with  the  addition,  on  rare  occa- 
sions, of  injections  of  morphine.  On  account  of  the  violent  agita- 
tion and  liability  to  collapse  in  these  cases,  I do  not  employ  baths, 
but  merely  resort  to  sponging  with  water  containing  aromatic 
vinegar,  keeping  the  patient  in  bed.  In  very  robust  individuals, 
and  at  the  outset  of  the  disease,  plentiful  blood-letting  has  given 
in  acute  delirium,  as  in  acute  sensory  delirium,  rather  satisfactory 
results. 


CHAPTER  XXIV 


PELLAGROUS  INSANITY 

This  is  a disease  arising  from  intoxication  of  the  nervous  system. 

It  is  confined  to  certain  regions  in  Italy,  Greece,  Roumania,  Russia, 
Bulgaria,  and  other  countries.  It  is  more  common  in  Italy  than  j 
elsewhere,  and  is  there  limited  to  Northern  and  Central  Italy,  more  ‘ 
especially  the  regions  of  Venice,  Emilia,  certain  frontier  provinces, 
Umbria,  Tuscany,  and  other  districts  of  the  valley  of  the  Po.  It  is 
almost  unknown  in  the  South  of  Italy.  A few  cases  of  it  have  been  , 
observed  there,  as,  for  example,  that  described  by  Venturi.  1 

Symptomatology. — Speaking  generally,  the  disease  appears  in 
spring,  but  more  frequently  in  May  and  the  beginning  of  June.  It  is 
ushered  in  with  vague  general  symptoms — weariness,  loss  of  energy,  I 
heaviness  of  the  head,  and  general  depression.  Soon  there  appear 
dryness  of  the  fauces  and  mouth,  intense  thirst,  and  difficultj^  in  ; 
swallowing.  A'ague  pains  in  the  limbs  and  back,  pariesthesias,  | 
humming  in  the  ears,  and  especially  vertigo,  give  rise  to  a pro-  ,| 
nounced  feeling  of  malaise.  This  train  of  symptoms  very  soon  j 
becomes  associated  with  an  erythema  of  a dark  red  colour  on  the 
exposed  parts  of  the  body — the  face,  neck,  and  hands — and  small 
bulke  often  appear  at  some  points  of  the  erythematous  surface. 
The  patient  complains  of  itching  in  the  erythematous  parts.  These 
soon  become  covered  with  small  scales,  which  are  continually  falling 
off  and  forming  again,  like  small  powdery  lamellae,  and  on  the  neck, 
being  limited  to  the  exposed  part,  they  give  rise  to  a contrast  in 
colour,  resembling  a collarette,  which  has  been  described  as  the 
pellagrous  collar.  Sometimes,  instead  of  scales,  crusts  form.  In 
addition  to  this  special  dermatitis,  there  soon  occur  noises  in  the 
head  or  in  the  ears,  vertigo,  jlrostration  of  strength,  cramps,  and 
pains  in  the  limbs.  In  a short  time  there  are  added  to  the  initial 
want  of  appetite,  pains  in  the  stomach,  abdominal  cramps,  p\TOsis  j 
(parageusia),  and  diarrhoea.  The  prostration  increases,  and  signs 
of  melancliolia  and  dejection  appear.  In  some  cases  there  is  also 
a troublesome  and  painful  stomatitis,  with  erythematous  or  aphthous  > 

760 


PELLAGROUS  LN SANITY 


761 

characters,  perverting  the  sense  of  taste,  so  that  to  the  patients  all 
things  are  salt  or  bitter,  for  which  reason  the  Venetians  called  the 
malady  the  ‘ salt  disease.’ 

The  intense  thirst  is  complicated  by  a feeling  of  insatiable  hunger. 
In  some  cases  the  disease  runs  a febrile  course. 

The  nervous  phenomena  dominate  the  scene  in  pellagra.  We 
may  classify  the  different  varieties  in  two  groups — the  chronic  and 
the  acute.  The  former  is  characterized  by  general  depression, 
progressive  wasting,  melancholia,  confusion,  slow  dementia,  parces- 
thesias,  alterations  of  motility,  ataxic  gait,  gastro-intestinal  dis- 
turbances, obstinate  diarrlioea,  and  albuminuria  from  nephritis. 
In  this  group  contractures  and  subsulti  are  absent,  although  in 
most  instances  the  reflexes  are  exaggerated. 

In  the  acute  varieties  we  have  rapid  elevation  of  the  temperature, 
which  may  reach  39°  and  even  41°  C.  ; intense  neuro-miiscular 
excitement,  subsulti  — spontaneous  or  provoked  — contractures, 
muscular  rigidity,  more  marked  exaggeration  of  the  tendinous 
reflexes,  more  pronounced  confusion,  with  phases  of  exaltation. 
Sometimes  this  acute  form  of  pellagra,  which  has  also  been  called 
pellagrous  typhus,  develops  in  the  chronic  sufferers.  Between  the 
two  groups  we  find  numerous  intermediate  forms,  in  which  we 
observe  a great  variety  of  psychic  phenomena,  and  also  alternations 
of  excitement  and  depression.  In  all,  however,  the  characteristic 
features  are,  on  the  one  hand,  the  erythema,  on  the  other  the  con- 
fusion and  the  slow  mental  enfeeblement.  Phases  of  remission  and 
also  of  apparent  recovery  are  observed  in  the  course  of  the  disease, 
especially  in  certain  seasons,  a fact  that  very  probably  has  some 
relation  to  the  phases  of  life  of  the  fungi  which  appear  to  give 
rise  to  it. 

.Etiology.  —The  old  doctrine  of  Lombroso,  who,  with  his  wonted 
acumen,  noticed  the  genetic  connection  between  the  use  of  diseased 
maize  and  the  development  of  pellagra,  a doctrine  confirmed  by 
the  studies  of  Bordoni-Uffreduzzi,  Seppilli,  Sormani,  Monti,  Pellizzi 
and  Tirelli,  Gosio,  Ferrati,  Antonini,  and  others,  has  quite  recently 
found  confirmation  in  the  interesting  researches  of  Ceni  and  Besta 
in  the  Phreniatric  Institute  of  Reggio  Emilia.  These  last  two 
investigators  undertook  a systematic  examination  of  all  that  had 
a bearing  upon  the  genesis  of  pellagra,  and  they  found  that  amongst 
the  diverse  fungi  growing  on  what  we  call  diseased  maize  the  two 
most  important  were  Penicillum  glaucuni  and  Aspergillus  fumi- 
gatus.  Of  the  former  they  have  studied  two  varieties — a and  h. 
The  chronic  variety  of  pellagra  of  a depressive  character,  and 
without  phenomena  of  excitement,  would  coincide  with  the  variety 
a,  of  Penicillum  glaucum.  With  the  variety  h there  would  coincide 
the  subacute  forms  in  which,  though  we  have  the  presence  of 
psycho-motor  excitement  not  very  intense,  a slight  spasmodic  state 


1^ 


762  PSYCHIATRY 

of  the  musculature,  exaggeration  of  the  reflexes,  and  spastic  para-  | 
paresis,  as  well  as  ^muscular  tremors,  yet  there  are  absent  true  I 
subsulti,  and  the  tetanoid  rigidity  of  the  muscles  which  are  charac-  ; 
teristic  of  pellagrous  typhus,  which  should  be  attributed  to  the 
Aspergillus  fumigatus.  Ceni  and  Besta  reject  the  theory  that  the 
morbid  phenomena  are  produced  by  phenol  compounds,  such  as 
tliQy  produce  in  culture  media,  and  they  support  the  hypothesis 
that  the  toxic  principles  are  due  exclusively  to  the  germ  (spores 
and  mxycelia).  They  conclude  that  both  the  Penicillum  glaucum  i 
and  the  Aspergillus  fumigatus  play  a very  important  part  in  the 
aetiology  of  pellagra,  and  that  their  action  can  be  explained  only 
by  their  determining  phenomena  of  progressive  intoxication  by 
means  of  the  toxines  they  set  free  in  the  gastro-intestinal  canal. 

In  the  case  of  the  Aspergillus  fumigatus,  Cent’s  idea  is  that  we 
have  to  deal  with  an  infection  rather  than  an  intoxication,  a fact 
that  would  also  be  proved  by  the  mode  of  commencement  and  the 
course  of  pellagrous  typhus,  which  have  all  the  characteristics  of 
an  acute  infective  process,  and  not  of  an  intoxication. 

In  any  case  we  have  to  deal  with  a disease  produced  by  food- 
stuffs (bread,  cake,  polento)  made  from  diseased  (mouldy)  maize.  | 

Pathological  Anatomy. — In  addition  to  the  cutaneous  alterations,  j 
consisting  in  a more  or  less  extensive  atrophy  of  the  layers  of  the  | 
epidermis  and  the  true  skin  with  thinning  and  sclerosis  of  the  skin,  ,| 
and  those  found  in  most  of  the  organs,  especially  the  intestine,  the 
serous  membranes,  and  the  kidneys,  by  Vassale,  and  produced 
experimentally  by  Ceni,  I must  make  special  mention  of  the  altera-  ; 
tions  of  the  abdominal  sympathetic  system  (Babes  and  Fox),  and 
the  parenchymatous  neuritis  found  by  Dejerine.  In  the  brain  we  ; 
find  thickening,  turbidity,  and  often  adhesions  of  the  meninges, 
atrophy  and  induration  of  the  cerebral  substance,  increase  of  the 
subarachnoid  fluid,  profound  alteration  of  the  cerebral  cells,  and  , 
increase  of  the  neuroglia.  In  the  acute  cases  the  usual  cell-altera-  | 
tions  are  those  found  in  other  acute  forms  of  psychosis.  In  the  | 
spinal  medulla  lesions  are  found  in  the  various  bundles  (Tonnini),  j 
just  as  in  progressive  paralysis.  In  one  case  the  pyramidal  bundles  | 
are  most  affected,  in  another  the  sensory  bundles,  in  a third  the  j 
central  substance.  Belmondo  {Riv.  Sper.  di  fren.,  1889-90)  found  | 
degeneration  of  the  pyramidal  bundles  of  various  intensity.  Babes  j 
and  Sion  found  lesions  closely  resembling  those  of  tabes,  such  as  j 
degeneration  of  the  posterior  roots  and  columns.  These  lesions  | 
are  most  frequent  in  the  cervical  segment.  In  the  chronic  form  | 
running  a slow  course  the  anatomo-pathological  alterations  are  j 
thus  very  similar  to  those  of  progressive  paralysis  and  of  tabes  I 
dorsalis.  j 

Therapy. — W'e  must  concern  ourselves  with  the  prophylaxis  1 
rather  than  the  cure  of  pellagra,  which  ma}^  be  regarded  as  a disease  j 


PELLAGROUS  INSANITY 


763 

associated  with  poverty.  It  reveals,  indeed,  a painful  state  of 
affairs  to  say  that  in  precisely  those  regions  in  Italy  where  the 
people  are  fairly  comfortable  as  compared  with  other  districts,  or 
have  become  so  in  the  last  forty  years,  comparatively  little  has  been 
done  to  get  rid  of  this  scourge.  If  the  doctrines  of  the  toxic  or 
infective  genesis  of  pellagra  are  true,  as  cannot  be  doubted,  it 
would  be  quite  sufficient  to  prevent  the  use  of  diseased  maize 
in  the  regions  most  afflicted. 

Urgent  provisions  are  required  when  we  consider  the  figures  of 
the  victims  of  pellagra.  In  the  frontier  districts  alone  the  mor- 
tality  from  pellegra  in  the  triennium  1887-89  reached  tne  figure  of 
1,481,  and  in  the  triennium  1895-97  the  figure  of  1,960.  In  the 
same  periods  of  time  the  pellagrous  insane  were  respectively  1,627 
and  1,138.  Quite  as  discouraging  are  Agostini’s  statistics  of  pellagra 
in  Umbria. 

On  the  one  hand,  we  ought  to  advert  to  the  best  mode  of  pre- 
paration and  preservation  of  the  maize,  and,  on  the  other,  we  should 
oblige  people  in  the  country  to  use  bread  made  from  grain  instead 
of  maize.  This  is  a matter  that  should  be  taken  up  by  the  Govern- 
ment, societies  of  public  health  and  improvement,  and  by  the  land 
proprietors.  The  price  of  maize  differs  greatly  from  that  of  grain, 
but  when  we  think  of  the  enormous  difference  between  the  nutri- 
tive power  of  the  two  cereals,  I believe  that,  with  a little  tact,  we 
could  secure  a complete  victory  for  civilization,  animated  and 
urged  on  by  scientific  researches. 

The  difficulties  in  our  way  are  less  formidable  than  in  the  case 
of  malaria,  syphilis,  and  alcoholism.  Pellagra  is  one  evil  which, 
given  the  seriousness  of  our  cognitions,  should  disappear  at  no  ver}^ 
remote  time. 


CHAPTER  XXV 


i 
1 

I 

ALCOHOLIC  INSANITY  | 

I 

The  action  displayed  by  alcohol  in  the  tissue  metabolism,  its  effect  j 
thereon,  and  the  influence  it  exercises  on  the  nervous  dynamism,  ' 
are  still  to-day  the  subject  of  keen  discussion. 

The  old  doctrine  which  looked  on  alcohol,  within  certain  limits,  : 
as  a food  substance — a substance  of  spare  material,  furnished  with  i 
exciting  power — has  in  these  days  been  displaced  by  the  teachings  , 
of  Binz  and  of  Duclaux.  I 

The  former  of  these  observers  has  demonstrated  the  exciting  f 
power  of  alcohol  quite  apart  from  any  reflex  action  and  its  supposed 
paralyzing  effect  on  the  inhibitory  centres. 

Further,  he  affirms  that  alcohol  belongs  to  those  stimulants  1 
which  always  determine  wider  deviations  of  the  mind  in  an  opposite  I 
direction. 

The  same  observer  and  his  followers,  Heubach  and  Bodlander,  j 
as  well  as  Strassmann,  Atwater,  Benedict,  and  others,  have  shown 
that  90  to  99  per  cent,  of  alcohol  taken  in  small  doses  becomes  oxy- 1 
dized  (90  per  cent.,  according  to  Strassmann  ; 95  per  cent.,  according  | 
to  Bodlander  ; 99  per  cent.,  according  to  Atwater  and  Benedict).  | 
On  the  other  hand,  we  know  that  doses  of  from  36  to  80  grammes  ^ 
of  alcohol  cause  a fall  in  temperature  of  from  0-3°  to  o-6°  C.  (Daub). 
It  is  not  very  clear  whether  it  is  to  the  ready  oxygenation  of  the 
greater  part  of  the  alcohol,  and  the  consequent  development  of  vital 
force  and  heat,  that  we  must  attribute  the  sparing  of  the  hyrdocarbons 
and  nitrogenous  compounds  from  combustion,  or  whether  this  is 
due  to  the  fact  that  alcohol  interferes  with  the  general  metabolism, 
so  that  oxygenation  of  the  tissues  occurs  less  freely.  The  researches  i 
of  Zuntz,  Bodlander,  Wolfers,  Geppert,  and  Neumann  conlirm, 
although  not  in  a decided  manner,  the  hypothesis  that  alcohol  is  a ; 
reserve  food  when  administered  habitually  and  in  small  doses.  ' 

Nevertheless,  there  are  many,  amongst  them  Kossowictz,  who  ; 
hold  that  alcohol  is  a toxic  substance,  and  that  a toxic  substance 
cannot  be  a food.  WT  may  admit,  however,  on  the  basis  of  the  re- 
searches of  Chauveau  and  the  statements  of  Duclaux,  that  alcohol  | 

764 


ALCOHOLIC  INSANITY 


765 

is  a stimulant  when  taken  in  small  doses,  say,  of  not  more  than  a 
litre  of  wine  of  7 per  cent,  to  8 per  cent,  in  the  twenty-four  hours. 
Beyond  this  measure  alcohol  must  be  regarded  as  a poison  which 
tends  to  destroy  the  nitrogenous  substances  in  the  organism,  altering 
profoundly  the  tissue  metabolism,  the  chemistry,  and  the  activity 
of  the  nerve-element,  and  predisposing  to,  and  in  the  long-run 
actually  producing,  insanity,  or  the  ethic  degeneration  of  individual 
and  family. 

Xo  one  has  been  able  to  follow  the  ethic  degeneration  produced 
by  alcohol,  even  up  to  delirium  tremens,  better  than  Zola  in  the 
character  of  Couteau. 

Without  fear  of  exaggeration,  and  without  supporting  the  extreme 
views  of  those  who  attribute  the  greatest  part  of  delinquency 
and  other  social  calamities  to  alcohol,  or  of  those  who  attribute  to 
the  use  and  abuse  of  alcohol  little  or  no  influence  on  the  human 
destinies,  and  without  sharing  the  pessimism  of  Everest,  for  example, 
and  the  statistic  criticism  of  Colajanni  (U Alcoolismo,  Sue  conse- 
guenze  morali,  1877),  we  must  recognise  the  fact  that  a good  part  of 
delinquency  must  be  put  down  to  alcohol  directly  or  indirectly, 
and  that  many  grave  psychopathic  forms,  especially  those  of  the  first 
group,  originate  from  the  abuse  of  alcohol  by  the  parents  (phrenas- 
thenias,  congenital  criminality,  epilepsy,  paranoia).  In  this  respect 
the  meritorious  contributions  of  Robinovitch,  of  Seppilli  and  Lui 
(Statistica  sulla  pazzia  nella  provincia  di  Brescia,  1899),  and  of  Lui 
(‘  Ereditd  e Alcoolismo, Annali  di  neurologia,  anno  xviii),  are  well 
worth  consideration. 

The  index  of  capacity  for  alcohol  varies  greatly  in  different  men 
and  according  to  habit. 

Those  who  are  intolerant  are  in  great  part  neuropathic  by 
heredity  ; epileptics  feel  the  hurtful  influence  of  alcohol  most  of  all. 

In  some,  small  doses  of  alcohol  produce  intoxication,  whilst 
in  others  large  doses  are  necessary. 

Symptomatology  of  Acute  Alcoholic  Intoxication  commonest 

form  is  drunkenness. 

Drunkenness  presents  various  stages.  It  is  generally  preceded 
by  a certain  degree  of  psychic  exaltation,  with  increased  affective 
excitability,  impulsiveness,  aggressiveness,  obscene  language,  or 
coprolalia.  With  the  continuation  of  drinking,  two  phenomena 
appear  on  the  scene — staggering,  owing  to  the  diminution  of  mus- 
cular tone,  with  all  the  features  of  the  cerebellar  syndrome  ; and 
mental  dissociation  (incapacity  to  preserve  the  logical  course  of 
thought). 

At  a further  stage  of  intoxication,  somnolence,  sleep,  and  a 
comatose  or  sub-comatose  state  come  on.  From  slight  staggering 
we  pass  to  a true  ataxic  condition,  or  a state  of  astasia-abasia,  and 
finally,  losing  all  strength,  the  drunken  person  falls  wherever  he  is — 


766 


PSYCHIATRY 


in  the  snow,  in  the  mud,  or  on  the  open  roadway.  Tn  this  state  there 
is  a diminution  in  the  arterial  pressure.  In  the  dog  Binz  found  it 
lowered  to  77  millimetres  from  the  normal  of  150  to  170.  This 
explains  the  cyanotic  aspect  of  drunken  individuals. 

The  temperature  is  lowered.  Magnan  found  the  rectal  tempera-  : 
ture  in  one  woman  to  be  26°  C.  Reineke,  in  a man,  found  it  24°  C.  ' 
Such  a lowering  of  temperature  is  due  to  two  causes — diminution  of 
production,  and  greater  loss  of  heat  owing  to  vaso-motor  paralysis 
of  the  cutaneous  vessels.  In  this  condition  collapse  may  occur. 
As  a rule,  we  have  recovery  from  such  a state.  j 

Acute  Alcoholic  Insanity  may  assume  any  form — mania,  melan-  . 
cholia,  stupor,  mental  confusion,  paranoia,  hallucinatory  insanity, 
congestive  attack  with  coma,  and  other  somatic  syndromes. 

Alcoholic  mania  may  reach  any  grade.  It  is  a common  i 
saying  that  alcohol  soon  ‘ loosens  the  tongue.’  The  intoxi- 
cated individual  becomes  happier,  more  self-assured,  less  diffi- 
dent, more  loquacious  than  usual,  expansive,  generous,  confident, 
gesticulates  more,  and  his  features  are  more  vivacious.  He  is 
more  credulous  and  more  open  to  suggestion  when  humoured, 
whilst  he  is  violent,  threatening,  and  impulsive  when  opposed.  | 
The  somatic  phenomena  of  mania  coexist.  In  this,  however,  as  i 
in  all  other  forms  of  alcoholic  psychosis,  there  is  evident  weakness  of 
the  higher  powers  of  the  mind.  Prudence  and  moderation  in  speech  ■ 
disappear  ; even  against  his  own  interests  the  drunken  maniac  reveals  ! 
compromising  affairs.  It  is  well  known  that  some  sharpers  make  use 
of  alcohol  to  entrap  their  victims  ; as  the  old  adage  has  it,  ‘ in  vino  ■ 
veritas.’  i 

In  the  typical  and  severer  form  (furor),  the  rapidity  of  the  course  ^ 
of  ideas,  the  hostility  of  the  mind,  the  intolerance,  the  tendency  to  ■ 
react  (cortical  irritability^),  the  desire  for  violent  destruction,  the 
impulsiveness,  the  aggressive  and  threatening  attitudes,  are  all  more 
accentuated  than  ever,  resembling  somewhat  the  excited  and 
sinister  mind  of  the  epileptic. 

Alcoholic  Melancholia,  far  from  having  the  dramatic  charac- 
teristics of  pure  melancholia,  is  infantile. 

The  melancholic  drunkard  is  sad,  easily  annoyed,  and  irritable. 
He  readily  gives  way  to  weeping,  without  being  able  to  explain,  even 
to  himself,  the  reason  why.  Often  he  has  hallucinations  of  fire, 
demons,  and  hell.  He  blames  himself  for  his  intemperance,  his  : 
wicked  conduct,  the  injury  he  has  done,  his  sins,  exaggerating  them  | 
all,  as  in  ordinaiy  melancholia. 

He  has  strange  and  painfal  sensations,  a tear  of  death  or  torture, 
and  a sense  of  impending  disaster.  In  a childish  manner,  he  asks 
pardon  of  his  wife  lor  tlie  irregular  life  he  has  been  leading  ; he  gives 
way  to  despair  and  to  sudden  impulses,  and  during  such  periods  he  ^ 


ALCOHOLIC  INSANITY 


767 

breaks,  destroys,  wounds  and  kills,  or  he  butts  his  head  against 
• the  wall,  or  attempts  other  modes  of  suicide.  Other  patients 
. present,  either  from  the  outset  or  after  a time,  vivid  hallucinations 
with  terrifying  content,  or  kinaesthetic  and  tactile  hallucinations 
which  give  rise  to  very  intense  fear  and  pronounced  agitation,  with 
deliria  and  suicidal  tendencies. 

Hallucinatory  Delirium  is  not  rare,  and,  as  a rule,  it  is  intense. 

The  hallucinations  are  of  terrifying  content,  the  agitation  is 
pronounced,  the  confusion  is  profound,  and  is  followed  by  a stuporous 
phase.  Many  cases  of  polyneuritic  psychosis  are  of  alcoholic  origin. 

The  most  frequent  form  is  acute  hallucinatory  paranoia,  with 
hallucinations  of  armed  foes,  reports  of  firearms,  masked  men  (ugly 
and  threatening),  shouts,  blood,  strife,  corpses,  etc.  The  agitation 
here  is  more  violent  than  in  ordinary  hallucinatory  paranoia,  and  the 
reaction  is  more  immediate,  impulsive,  and  savage.  The  alcoholist, 
like  the  epileptic,  quickly  seizes  the  first  weapon  on  which  his  eye 
alights,  and  uses  it  in  a ferocious  manner.  Sometimes  there  are  oneiric 
hallucinations,  the  images  of  which  are  prolonged  into  the  conscious 
state,  and  possess  strong  determinative  power.  A young  student  X., 
confined  in  the  Sales  Asylum  under  legal  warrant,  had  been  drinking 
the  previous  evening.  During  the  night  he  dreamt  of  foes,  and 
called  out  against  them.  He  woke,  seized  his  revolver,  and  killed 
an  unfortunate  man  who,  having  heard  his  shouts  from  a neighbour- 
ing room,  had  run  to  his  aid. 

Sometimes  there  are  epileptic  attacks,  with  brief  phases  of  post- 
epileptic delirium. 

Pianetta  has  described  forms  of  alcoholic  insanity  closely  re- 
semblmg  the  epileptic  equivalents,  such  as  those  described  by  Samt, 
j Lombroso,  Tamburini,  and  others.  These  forms  are  characterized 
: by  an  abrupt  mode  of  onset,  rapid  and  violent  development  of  the 
somatic  picture,  followed  by  prompt  disappearance  of  the  pheno- 
mena,  with  psychic  reintegration  and  loss  of  memory  of  the  delirium. 

Speaking  generally,  the  hallucinatory  delirium  presents  no  par- 
ticular  features  apart  from  the  more  rapid  course,  more  vivid  hallu- 
cinations, and  more  accentuated  impulsiveness ; phenomena  of 
mental  deficiency,  especially  of  the  memory,  are  frequent.  Recovery 
, is  comparatively  prompt,  but  sometimes  we  have  not  long  to  wait 
f for  an  issue  in  dementia  in  predisposed  individuals, 
i When  the  delirium  runs  a chronic  course,  there  is  a prevalence  of 
ideas  of  persecution  and  jealousy. 

Jealousy  pushed  to  the  degree  of  paranoia,  or  rising  to  an  obses- 
sive form,  often  a cause  of  uxoricide,  is  due  to  the  mental  and  ethic 
, enfeeblement  of  the  alcoholist,  and  to  his  sexual  impotence  (frequent 
in  habitual  alcoholists,  especially  when  mental  enfeeblement  has 
commenced). 

The  chronic  mental  alterations  produced  in  the  long-run  by  the 


768 


PSYCHIATRY 


abuse  of  alcohol,  have  reference  to  the  sentiments  and  the  intellect, | 
the  former  suffering  grave  injury  much  sooner  than  the  latter.  Thef 
chronic  alcoholist  is  a degraded  individual  both  morally  and  socially. | 
The  sense  of  dignity  and  self-respect  diminishes,  and  then  disappears.' 
The  sentiment  of  duty  gradually  lessens  ; business  and  personalj 
interests  are  neglected,  work  abandoned,  the  household,  personal 
and  family  property  neglected;  the  education  of  the  children  proceeds, 
no  further  ; the  wife  is  left  to  herself  ; the  husband  no  longer  pro- 
tects her  or  pays  her  attentions,  and  he  becomes  jealous  of  her.'* 
There  is  no  order  or  method  in  the  family  and  profes’sional  life. 

The  alcoholist  is  trivial,  obscene,  humble,  and  vice  versa,  irascible,: 
impulsive  and  violent,  like  the  epileptic.  He  isolates  himself  from, 
society,  which  on  its  part  despises  him.  The  sense  of  honour,! 
decency,  propriety,  and  the  moderation  of  the  polished  and  educated' 
man  are  no  longer  evident.  i 

His  debauchery  opens  the  way  to  lewdness  in  his  home  ; hisi 
work  is  more  and  more  neglected  ; he  is  fond  of  idleness,  of  wander- 1 
ing,  of  playing  cards  ; he  becomes  instinctive,  and  abandons  himself 
to  the  suggestion  of  crime.  Thus,  delinquency,  in  about  half  the: 
cases,  becomes  the  ordinary  accompaniment  of  the  abuse  of  alcohol. 
The  few  figures  which  I give  sum  up  the  whole  doctrine  of  the  influ-, 
ence  exercised  by  the  abuse  of  alcohol  as  one  of  the  causes  of  morahj 
decadence  in  the  individual  and  in  the  race. 

According  to  one  statement  of  Bang  (Norwa}"),  of  1,232  crimes, :| 
547  (44-4  per  cent.)  were  attributable  to  drunkenness. 

In  Russia,  according  to  the  recent  statistics  of  Grigorieff  quoted  by  I 
Matti  Helenius,  in  3,226  crimes  committed  in  the  territory  of  Kasan ; 
from  1885  to  1894,  42-68  per  cent,  were  connected  with  drunkenness.] 
Of  13,687  persons  who  committed  crimes  against  property  in  thej 
city  and  province  of  St.  Petersburg,  43-3  per  cent,  were  alcoholists.| 

In  France,  according  to  the  report  of  Guillemet,  delinquency; 
has  risen  where  the  consumption  of  alcohol  has  increased,  a fact 
which  coincides  with  the  researches  of  Ferri,  who  found  a diminu- 
tion in  the  proportion  of  certain  crimes  in  those  years  in  which  the 
vine  crops  were  very  bad,  and  with  those  of  ]\Iarambat  dealing  with 
prisons,  where,  of  the  thieves  and  coiners,  1,146  in  1898  (70  per  cent.) 
were  alcoholists. 

Of  Germany,  I can  give  only  the  statistics  of  Baer  (‘  Alco- 
holismus  ’),  who  found  amongst  32,837  prisoners  in  various  establish- 
ments 41-7  per  cent,  of  drinkers. 

In  England,  even  although  we  do  not  take  into  account  the  j 
Parliamentary  and  other  inquiries  of  the  years  1834,  1850,  1872,  | 
which  set  down  two-thirds  to  three-fourths  of  the  crimes  to  an, 
alcoholic  origin,  nevertheless  the  result  of  that  of  the  Royal  Com- : 
mission  of  1899,  which  attributes  at  least  50  per  cent,  of  crimes  to 
alcohol,  must  be  regarded  as  very  probable  (Royal  Commission  on 
Liquor  Licensing  Laws,  Final  Report,  London,  1899).  | 


ALCOHOLIC  INSANITY 


769 

In  America,  the  researches  of  Hargreaves  and  of  Mann  show 
that  no  less  than  25  per  cent,  to  30  per  cent,  of  the  insane  in  asylums 
owe  their  trouble  directly  cr  indirectly  to  the  abuse  of  alcohol. 
Further  on  we  shall  discuss  the  pathogenic  action  of  alcohol  in 
progressive  paralysis,  but  in  the  meantime  it  is  beyond  question 
that  a certain  number  of  epilepsies  are  of  alcoholic  origin.  Westphal 
Tuczeck,  Wartmann,  Kraepelin,  Fere,  and  lastly  Robinovitch,  iii 
strong  articles  have  sought  to  demonstrate  the  epileptogenic  action 
of  alcohol.  It  is  true  that  some  (Magnan,  Bleuler)  attribute  this 
toxic  action  less  to  alcohol  than  to  the  extraneous  substances  con- 
tained m some  alcoholic  beverages  (absinthe,  fusel  oil  in  whisky, 
etc.),  but  I do  not  believe  that  the  figures  dealing  with  the  victims 
of  alcohol  can  thus  be  reduced  to  any  appreciable  extent.  In 
Italy,  where  pure  wine  is  drunk,  and  where  only  a very  small 
quantity  of  other  alcoholic  drinks  is  consumed,  the  psychoses  and 
epilepsies  due  directly  or  indirectly  to  alcohol  attain  a figure  which, 
though  not  so  high  as  in  some  other  countries,  is  considerable.  I 
ought,  however,  to  add  that  many  individuals  with  hereditary 
nervous  taint,  and  especially  the  children  of  epileptic  drunkards 
are  strongly  predisposed  to  drink.  In  these  cases  the  drunkenness 
complicates  and  aggravates  the  predisposition. 

A short  time  ago  I was  called  upon  to  e.xpress  an  opinion 
on  a grave  uxoricide  committed  by  a gentleman  who  certainly 
loved  his  wife,  but  owing  to  his  drinking  habits  neglected  her 
Almost  every  day  he  left  the  house  after  dinner,  spent  his  time 
in  the  taverns  of  the  neighbourhood,  and  nearly  every  night 
returned  home  drunk.  Arriving  home  very  late  one  night,  he  asked 
his  wife  for  a bottle  of  wine.  He  hurriedly  gulped  down  the  wine, 
and  being  unwilling  to  go  to  bed,  went  to  sleep  on  a mattress  which 
had  been  placed  for  him  near  the  kitchen  fire.  Several  hours  after- 
wards he  awoke,  and,  going  into  the  bedroom,  seized  his  wife,  and 
drew  her  out  of  bed  on  to  the  floor,  took  a gun,  and  pointed  it  at  her 
breast.  The  woman  struggled  desperately  and  disarmed  the  mad- 
man ; then  unloaded  the  gun,  and  went  to  calm  the  little  children, 
errified  by  the  savage  scene.  Meanwhile,  the  husband  reloaded 
the  weapon,  and,  firing  at  his  wife,  killed  her.  He  now  remembers 
the  particulars  of  the  affair. 

There  is  no  doubt  that  in  Italy,  where  pure  grape  wine  is  drunk, 
a 110  small  percentage  of  psychopathies  and  delinquencies  is  due  to 
the  abuse  of  alcohol. 

Many  criminals  drink  before  committing  a crime,  because  the 
alcohol  dissipates  all  remorse  or  timidity.  The  criminal  nature 
nnds  Its  homogeneous  medium  in  alcohol.  Thus,  the  soldiers 
- IS  ea  and  Radici,  the  youth  Caruson,  and  others,  had  been 
arinking  before  they  committed  their  crimes. 

alcoholism  induces  a rapid  psychic  disturbance, 
th  disgregation  of  the  personality  in  its  higher  developments, 

49 


PSYCHIATRY 


770 


chronic  alcoholism  induces  a gradual  lowering,  even  to  disappear-  | 
ance,  of  the  ethic  sentiments  in  man  (immorality  and  delinquency).  1 
No  less  important  are  the  facts  of  intellectual  enfeeblement,  although  | 

appearing  later.  i 

When  alcohol  reaches  the  anatomical  field  of  the  intellect,  the 
latter  is  not  slow  to  present  unmistakable  signs  of  enfeeblement.  1 
In  this  case  the  man  no  longer  possesses  his  habitual  perceptive 
readiness,  his  critical  acumen,  and  the  associative  facility  whence  | 
is  derived  the  imagination,  which,  accordingly,  becomes  poor  and 

childish.  i 

Neither  fineness  of  phraseology  nor  penetration  of  thought  is  ! 
any  longer  an  attribute  of  these  weaklings.  They  no  longer  take 
the  lead  in  conversation  ; their  discourses  are  inconclusive  or  trivial. 
The  imagination  is  poor  or  utterly  destroyed,  the  associations  occur 
slowly  and  are  commonplace.  Poverty,  slowness,  inefficacy  charac- 
terize the  products  of  thought  of  the  chronic  alcoholist.  There  is  j 
no  doubt  that  the  attentive  power  always  suffers  greater  or  less  | 
diminution,  but  the  effect  of  alcohol  on  the  associations  and  the  j 
memory  is  particularly  marked.  I 

The  memory  suffers  the  severest  loss.  Evocation  and  repro-  j 
duction  are  extremely  difficult.  Proper  names  are  quite  deleted 
from  the  mnemonic  register  ; then  an  increasing  number  of  nouns 
disappear,  and  verbs  and  adjectives  are  not  always  appropriate.  I 
The  language  becomes  poor,  primitive,  and  lacks  precision.  The  ■; 
amnesia  arrives  at  such  a point  in  some  cases  that  the  patients  | 
cannot  remember  a name,  even  when  it  is  repeated  to  them  miany  I 
times  in  succession. 

As  a rule,  these  phenomena  of  grave  amnesia  and  dementia  are  | 
accompanied  by  somatic  nervous  phenomena,  such  as  tremors  and  j 
coarse  vibrations,  which  are  more  evident  in  the  morning,  rigidity  ,| 
of  the  pupils,  exaggeration  or  diminution  of  the  patellar  reflexes,  1 
muscular  weakness,  pains,  parsesthesia  in  the  limbs  and  abdominal 
viscera,  zones  of  anaesthesia  and  analgesia,  sexual  paraesthesia  01 
impotence,  and  neuritis  with  muscular  atrophy.  This  syndrome 
might  be  mistaken  for  progressive  paralysis. 

It  is  a strange  fact,  as  Berkeley  has  noted,  that  these  phenomena  ^ 
of  grave  chronic  intoxication  are  more  frequent  and  pronounced  in 
persons  who  have  commenced  the  abuse  of  alcohol  at  a late  age  ■ 
than  in  those  who  from  an  early  age  have  graduall}"  accustomed  i 
themselves  to  the  action  of  this  poison.  ! 


Delirium  tremens  is  the  most  classic  form  of  alcoholic  insanit} . 
Fundamentally  it  resembles  acute  sensory  delirium,  with  phenomena  I 
of  collapse.  The  gastric  catarrh,  the  scanty  nutrition  of  those  who  | 
abuse  sp>irituous  liquors,  and  the  alterations  induced  by  the  alcohol  i 
in  all  tlic  organs,  but  especially  in  the  gastric  mucous  membiane  | 
and  in  the  tine  structure  of  the  nerve-elements,  predispose  to  collapse,  j 


ALCOHOLIC.  INSANITY 


771 


more  especially  in  those  who  for  several  days  have  partaken  of 
nothing  but  alcoholic  drinks.  We  must,  however,  take  into  account 
the  habituation  of  the  nerve-centres  to  the  stimulus  of  alcohol, 
since,  when  alcohol  is  completely  withdrawn,  there  takes  place  such 
a lowering  of  the  arterial  tension  as  to  give  rise  to  a true  aniemia, 
with  inanition  of  the  nerve-centres  and  phenomena  of  collapse,  like 
those  produced  by  poisoning  from  the  introduction  of  a large 
quantity  of  alcohol. 

The  attack  commences  with  unrest,  fear,  oppression,  a state  of 
anguish,  and  elementary  hallucinations  of  sight  and  hearing.  In 
a few  hours  or  days  delirium  bursts  forth,  accompanied  by  tremors 
and  albuminuria.  It  is  of  decidedly  hallucinatory  content,  and 
visual  hallucinations  prevail.  The  hallucinations  take  the  form  of 
domestic  animals  (dogs,  cats,  rats)  or  serpents,  which  turn  and 
move  about  continually,  leap  upon  the  bed,  on  the  bedclothes  on 
the  body ; or  of  tigers,  lions,  elephants,  which  dance  about  and 
m.ake  a terrible  noise  around  the  patient.  Sometimes  they  are 
phantasms  of  human  or  satanic  form— horrible,  threatening  figures. 
More  rarely  they  are  birds  flying  about,  or  worms  and  insects  swarm- 
ing over  the  skin,  and  causing  the  delirious  person  infinite  torments. 
Sometimes  they  are  the  bedclothes  transformed  into  gold  or 
covered  with  money,  nude  women,  or  erotic  scenes  with  sexual 
paraesthesias.  Auditory  hallucinations  are  somewhat  less  frequent 
—reports  of  firearms,  drums,  shouts,  whistling,  noise  of  wind, 
rustling  of  trees,  sound  of  falling  water,  etc.  It  is  remarkable  that 
the  attitude  of  the  patient  varies  as  scene  replaces  scene  in 
panoramic  succession.  He  withdraws  himself  from  the  real  world, 
and  is  now  terrified  and  frightened.  He  defends  himself  from  the 
attacks  of  animals,  brushes  his  skin  free  of  the  insects  with  which 
he  sees  himself  covered,  seeks  laughingly  to  catch  the  bird  which 
IS  flying  near  him,  gathers  in  his  hands  the  golden  pieces  he  sees 
on  the  bed,  assists  lasciviously  in  savage  scenes  of  love,  listens 
in  ecstasy  for  some  moments  to  music.  With  trembling  hands 
hollow  eyes,  dry  lips,  foetid  breath,  coated  tongue,  incapable  in 
most  instances  of  standing  erect  and  articulating  his  words 
correctly,  the  delirious  individual  is  like  one  in  a dream,  com- 
I pletely  withdrawn  or  abstracted  from  reality. 

He  believes  himself  to  be  in  another  place,  addresses  by  the 
names  of  known  persons  the  phantasms  he  sees,  mistakes  persons 
‘present  for  those  represented  to  him  by  his  imagination.  Some- 
times he  speaks  as  though  he  were  in  conversation,  and  often  he 
jcurses  his  enemies,  and  seeks  to  defend  himself  from  them,  or  from 
lanimals,  etc.  All  these  attitudes  are  logical  reflexes  of  the  hallu- 
ijcinations.  True  deliria  (infidelity  of  his  wife,  death  of  his  children 
31-  the  delirium  of  grandeur  or  persecution)  are  rather  rare,  and  are 
bnoted  during  intervals  between  the  hallucinations. 

1 Further,  it  is  not  rare,  in  the  milder  forms,  for  the  consciousness 

I 49—2 


772 


PSYCHIATRY 


to  become  partly  restored  during  the  pauses,  and  for  the  patient  to 
be  recalled  to  reality  (remissions). 

The  paranoid  deliria  may  be  more  persistent  and  better  organized, 
but  in  these  cases  we  have  not  infrequently  to  deal  with  deliria 
pre-existing  in  chronic  alcoholists  in  whom  the  delirium  tremens 
is  a more  or  less  fleeting  episode  of  a chronic  psychopathic  condition 
induced  by  the  abuse  of  alcohol. 

The  delirium  tremens  and  the  other  forms  of  alcoholic  psychosis 
are  often  found  associated  with  other  organic  symptoms  arising 
from  the  long-continued  and  hurtful  action  of  alcohol  on  the  organism. 
Apart  from  the  morning  vomiting,  and  the  vibratory  and  oscillatory 
tremors  which  are  more  marked  in  the  morning  and  more  evident : 
after  an  effort  or  on  the  continuation  of  a delicate  manipulation, ! 
the  delirium  tremens  is  sometimes  associated  with  a febrile  tempera- ; 
ture  of  some  decimals  (febrile  delirium  tremens  of  Magnan).  In  i 
such  cases  the  pulse  is  more  frequent,  weak,  and  compressible  ; the  i 
respiration  more  rapid  and  shallow.  Sometimes  there  are  cold 
sweats,  and  these  are  of  bad  augury. 

The  constituents  of  the  blood  present  various  alterations.  At 
the  height  of  the  delirium  tremens  the  proportion  of  leucocytes  is 
increased,  and  according  to  Elzholz,  there  is  an  increase  of  the  poly- , 
nuclear  cells.  1 

Albuminuria  is  frequent.  Fiirstner  found  it  in  40  per  cent,  of 
his  cases,  Naecke  in  82  per  cent.,  Liepmann  in  76  per  cent,  Friis  in 
32  per  cent.,  Krukenberg  in  52  per  cent.  It  is  purely  toxic,  and 
disappears  with  the  delirium  ; where  it  persists,  it  is  due  to  nephritis. 

The  issue,  as  a rule,  is  recovery. 

At  the  most,  20  per  cent,  of  the  cases  are  grave.  A fatal  issue; 
is  perhaps  more  frequent  in  countries  where  impure,  and  therefore! 
more  toxic,  alcoholic  substances  are  used. 

The  duration  of  the  attack  is  about  four  days  in  mild  cases,  and; 
from  ten  to  twelve,  or  even  more,  in  the  most  severe  cases. 

Pathological  Anatomy.— In  acute  alcoholic  delirium  we  find 
lesions  in  the  vessels  and  in  the  nerve-elements.  These  present  no, 
really  characteristic  features.  The  researches  of  ]\Iirzejewski,| 
Jakimow,  Vas,  Dehio,  Berkeley,  Andriezen,  and  others,  brought  to 
light  the  usual  alterations  in  the  chromatic  substance  of  the  nerve-: 
cell  with  Xissl’s  or  a similar  method,  or  atrophy  of  the  dendrites  and 
moniliform  swelling  of  the  protoplasmic  processes  (with  the  nitratej 
of  silver  staining  employed  by  Colella).  This  last  lesion  is  thought 
by  many  to  be  produced  by  the  method  of  staining.  There  are  no 
visible  alterations  of  the  fibrillar  substance  of  the  cell,  or  of  the  axis- 
cylinder  prolongation. 

The  alterations  found  in  the  vessel-walls  in  the  cortex  are  more, 
marked — swelling  of  the  nuclei  of  the  endothelium ; degenerative^ 
alterations  in  the  cell-protoplasm ; marked  degeneration  of  the  fibres| 


ALCOHOLIC  INSANITY 


773 

of  the  muscular  tunic  ; occlusion  of  the  perivascular  and  lymphatic 
spaces ; infiltration  of  leucocytes,  some  of  them  swollen  and  necrotic  ; 
swelling  and  occlusion  of  the  capillaries  with  white  corpuscles,  many 
of  them  necrosed  and  disintegrated.  These  degenerative  processes 
are  partly  explained  by  the  researches  of  Miink,  who  found  that  small 
doses  of  alcohol  diminish  the  quantity  of  nitrogen  in  the  urine  from 
6 to  7 per  cent.,  whilst  large  doses  increase  it  from  4 to  10  per  cent, 
(destruction  of  albuminoid  substances). 

In  chronic  alcoholism  we  find  great  diminution  in  the  resistive 
powers  of  the  nervous  tissues  and  of  the  tissues  in  general  ; 
from  this  arise  the  degenerations  of  the  specific  elements  and  the 
increase  of  the  connective  tissue — for  example,  hepatic  and  renal 
cirrhosis  ; atheroma  of  the  arteries  ; arterio-sclerosis  ; pachymenin- 
gitis ; ependymitis  ; turbidity  and  thickening  of  the  pia  ; increase 
of  the  neuroglia  ; profound  alterations  of  the  nerve-cell,  not  liaiited 
merely  to  the  chromatic  substance,  but  extending  to  the  reticulated 
substance  of  the  cell  and  of  the  nucleus  ; various  forms  of  degenera- 
tion pigmentary,  fatty,  hyaline,  etc.  In  some  cases  the  number 
dI  the  nerve-cells  is  diminished  ; in  others  the  cells,  and  especially 
the  pyramidal  cells  in  the  poylneuritic  forms,  present  the  axonal 
type  of  degeneration  (displacement  of  the  nucleus  and  disintegration 
)f  the  chromophilic  substance).  Lesions  are  also  found  in  the  spinal 
neduUa  and  peripheral  nerves.  In  some  cases  the  alterations  closely 
esemble  those  of  senile  dementia  and  of  dementia  paralytica. 

Therapy.'  The  prophylaxis  may  be  summed  up  in  the  diffusion 
)f  the  knowledge  of  the  dangers  of  alcohol.  It  would  be  necessary 
o prevent  marriage  among  alcoholists,  or  to  advocate  divorce,  since 
t is  well  known  that  a large  number  of  alcoholists,  epileptics, 
ohrenastheniacs  and  criminals  are  the  children  of  alcoholists.  The 
anitary  laws  should  condemn  the  sale  of  alcoholic  drinks  containing 
xtraneous  substances  which  increase  the  toxicity  of  alcohol.  The 
)ure  wine  of  the  Italian  vineyards  is  certainly  less  hurtful,  but  if 
a Italy  delirium  tremens  is  rare,  the  bad  effect  of  wine  on  the 
•roducts  of  fecundation  during  alcoholic  intoxication  of  one  or  both 
•arents  is  no  less  grave  [vide  chapters  on  phrenasthenia  and  epilepsy). 

The  therap}^  of  delirium  tremens  is  in  no  way  different  from  that 
^ f other  states  of  drunkenness  and  of  other  alcoholic  psychoses. 

In  drunkenness  it  is  beneficial  to  empty  the  stomach,  and  if 
here  is  cyanosis  or  lowering  of  the  temperature,  the  only  two  facts 
lat  call  for  active  medical  interference,  hot  coffee,  injections  of 
iffeine  or  ether,  massage  of  the  body,  hot  packs,  and  inhalation  of 
are  the  best  remedies. 

In  delirium  tremens  we  must  take  into  account  the  threatened 
inger  of  collapse.  It  is  therefore  necessary  to  keep  up  the  patient’s 
.rength.  Lavage  of  the  stomach  and  the  intestines  will  prove  useful, 
id  afterwards  nourishment  with  milk  and  soda-water.  If  the 


774 


PSYCHIATRY 


patient  refuses  food,  recourse  should  be  had  to  injections  of  pep' 
tones  or  to  the  stomach -tube. 

Nux  vomica  and  capsicum,  along  with  alkalies  and  rhubarb, 
will  facilitate  the  gastric  functions.  It  is  necessary  to  stimulate 
the  functions  of  the  liver. 

Hot  baths  at  35°  to  36°  C.  and  hypodermic  transfusions  are 
useful  if  the  renal  secretion  is  scanty. 

It  is  necessary  to  maintain  the  cardiac  function  at  a high  tone 
with  infusions  of  Adonis  vernalis  or  digitalis.  The  most  certain  seda- 
tive is  morphine.  Sulphonal,  trional,  or  veronal  may  also  be  of 
some  use.  In  the  chronic  psychopathies,  in  addition  to  hygiene  and 
the  treatment  of  the  gastric  and  intestinal  catarrh  and  constipation, 
bromides,  iodides,  and  tonics  are  excellent  remedies.  Hydrotherapy 
and  removal  to  the  country  are  good  and  useful  helps  ; inebriate 
homes  aim  at  breaking  off  the  drinking  habit. 


CHAPTER  XXVI 


MORPHINIC  INSANITY 

It  is  requisite  to  distinguish  between  the  psychopathic  condition, 
owing  to  which  an  individual  abandons  himself  to  the  abuse  of  opium, 
and  the  phenomena  of  poisoning  depending  on  the  long-continued 
use  of  that  drug  or  its  alkaloid,  morphine.  In  the  first  case  we  have 
to  deal  with  an  obsession  suggested  as  a rule  by  a medical  prescrip- 
tion— an  obsession  with  which  is  manifested  the  neuropathic  con- 
stitution. In  the  second  case  we  have  to  deal  with  nervous  and 
mental  disturbances  due  to  poisoning  with  the  drug — disturbances 
which  in  most  instances  are  not  genuine,  but  complicated  and 
mingled  with  the  primary  phenomena.  In  my  opinion  the  abuse 
of  morphine,  and  I might  say  of  almost  all  drugs  that  are  abused  by 
obsession,  mierely  puts  in  evidence  a pre-existing  anomalous  char- 
acter, psychopathic  to  a certain  degree,  but  concealed  by  the  con- 
trolling powers  which  were  active  to  some  extent  before  being  weak- 
ened by  some  difiiculty  or  embarrassment  in  life,  or  by  chronic 
morphine  intoxication  itself.  The  latter  is  the  expression  of  the 
modern  orientation  of  the  mind  in  the  struggle  against  pain,  and 
manifests  itself  in  various  forms,  which,  like  the  intoxications  from 
alcohol,  are  due  to  the  psychic  structure  and  mental  disposition  of 
the  individual. 

I would  say  that  in  the  majority  of  cases  there  is  a prevalence  of 
the  hysterical  character  as  manifested  in  that  form  of  monoideism 
and  of  intellectual  construction  which  we  find  in  the  torpid  variety 
of  hysteria  where  there  exists  a more  or  less  marked  stigma  (para- 
tysis,  anaesthesia,  contracture).  The  morphine  represents,  as  it 
were,  a pivot  round  which  the  whole  intellectual  patrimony  certainly 
revolves,  but  always  with  morphino-centric  movements,  these, 
further,  being  determined  by  continuous  organic  interchanges.  The 
fact  that  a lady  leaves  the  drawing-room  during  conversation,  and 
repairs  to  her  bedroom,  where  she  has  everything  ready  for  an  injec- 
tion of  morphine,  the  seductive  influence  of  which  she  is  unable  to 
resist,  or  goes  out  for  a drive  provided  with  her  inseparable  syringe, 
because  at  a certain  hour  she  will  be  unable  to  support  existence 

775 


776 


PSYCHIATRY 


without  the  refreshing  influence  of  that  solution  bringing  happiness 
in  its  train,  reveals  the  true  nature  of  the  mind  of  the  morphinist,  i 
and  how  precisely  this  substantial  and  primary  anomaly  may  com- 
plicate and  cloud  the  whole  clinical  picture  of  morphinism. 

The  great  excitability  of  character  assigned  to  the  morphinist, 
and  especially  the  mobility,  the  rapid  passage  to  psychic  contrasts, 
weeping,  laughter,  irascibility,  dramatic  poses,  lewd  and  obscene 
jokes,  moroseness,  unreliability,  reveal  a state  of  mind  pre-existing 
in  rudiment.  The  alternations  of  exaltation  and  calm,  the  tendency  ; 
to  lie  and  slander,  remind  us  of  hysteria.  Hallucinations  are  a j 
distinctly  morbid  phenomenon.  Some  consider  them  to  be  frequent,  j 
In  my  opinion,  they  are  very  rare.  In  go  per  cent,  of  cases  the 
morphinist  is  a hypochondriacal  person,  a fanatic  with  regard  to  his 
own  malady.  He  is  intolerant  of  pain  and  is  egocentric,  instinctive, 
and  impotent.  j 

Sometimes  accessions  of  mania  and  melancholia,  with  tendencies  i 
to  suicide,  arise.  Apart,  however,  from  these  more  pronounced  I 
forms  of  the  malady,  there  occur  nocturnal  fears  and  terrors.  In  ' 
one  case  I found  very  marked  tactile  hallucinations  of  small  animals  ■ 
which  appeared  to  mcve  over  and  under  the  skin.  To  these  features 
are  to  be  added  anaesthesia,  hyperaesthesia,  diminution  of  the  reflexes, 
increased  appetite,  and,  finally,  obstinate  constipation,  tenesmus,  ; 
dysuria,  impotence,  intermittent  pulse,  dyspnoea,  dryness  and  hard- 
ness of  the  skin,  furrowing  of  the  face,  marasmus,  and  insomnia.  , 

Phenomena  of  excitement  (irritability),  change  of  temperament, 
incapacity  for  work,  and  demoniacal  excitation,  unrest,  insomnia,  i 
hallucinations,  intellectual  weakness,  etc.,  are  observed  when  the 
use  of  morphine  is  suppressed.  This  agitation  with  hallucinations 
may  go  so  far  as  to  resemble  delirium  tremens.  ? 

Diagnosis, — ^The  diagnosis  of  morphinic  insanity  is  easy.  The  '* 
tendency  to  conceal  abuse  of  morphine  disappears,  revealing  the  ; 
real  state  of  the  patient,  who  will  now  present  the  skin  of  the  abdo- 
men and  of  the  thighs  covered  with  punctures.  Amongst  other  cases, 

I remember  that  of  a lady  sent  to  my  clinique  from  Constantinople, 
who  injected  no  less  than  2 grammes  of  hydrochlorate  of  morphine 
per  day,  and  had  the  skin  of  the  abdomen  and  thighs  raised  and 
darkened  as  though  tattooed.  It  was  a repugnant  sight.  Again, 
morphine  is  present  in  the  urine. 

Prognosis. — As  regards  the  prognosis,  it  is  stated  to  be  veiy  grave, 
for  perhaps  no  passion  is  so  tyrannical  as  that  of  morphine  ; the  | 
morphinist,  if  not  placed  under  treatment,  goes  on  to  marasmus  and 
phthisis.  I do  not  agree  with  this  pessimism.  I have  been  able  to  ' 
follow  for  several  3’ears  the  history  of  some  individuals  who  injected  ■ 
I or  2 grammes  of  morphine  per  da}-’  without  suffering  aiw  great 
injury.  Residence  in  a well-organized  and  strictly  disciplined 
hospital  succeeds  as  a rule  in  curing  this  malady. 


MORPHINIC  INSANITY 


in 


Therapy. — The  treatment  consists  in  the  suppression  of  the 
alkaloid,  but  this  must  be  neither  too  slow  nor  too  abrupt.  I have 
long  been  convinced  that  the  one  method  involves  a waste  of  time 
and  the  other  exposes  the  patient  to  serious  dangers. 

The  intermediate  method,  not  exactly  that  of  Erlenmeyer,  gives 
the  best  results,  and  is  most  certain.  It  is  necessary  to  have  at 
disposal  a trustworthy  and  competent  staff,  and  to  have  great  control 
and  inflexible  authority  over  the  patient.  The  great  secret  is  not 
to  give  way  to  the  entreaties  or  imprecations  of  the  patient,  to 
substitute  nothing  for  the  morphine  except  quinine,  iron,  arsenic, 
massage,  and  electricity.  The  cardiac,  gastric,  and  intestinal 
symptoms  are  cured  by  ordinary  means,  the  insomnia  by  warm  baths 
and  electricity.  In  some  cases  hypnotism,  rationally  employed,  as 
by  Tanzi,  will  prove  of  service. 


CHAPTER  XXVII 


COCAINIC  INSANITY 

This  is  more  serious,  but  fortunately  more  rare,’  than  morphinic 
insanity,  and  is  always  a complex  fotm,  showing  phenomena  of  the 
inherited  neuropathic  constitution,  on  which  cocainism,  like  mor- 
phinism, depends,  phenomena  of  cocainic  intoxication  being  super- 
added  later  on.  I have  observed  a few  cases,  and  have  formed  the 
opinion  that  in  the  mild  forms  cocainic  insanity  presents  no  notable 
differences  from  morphinic  insanity. 

In  some,  cocainism  has  been  primary,  in  others  it  has  been  secon- 
dary to  the  morphinism,  and  generally  substituted  therefor  by 
medical  advice,  yet  it  is  to  be  regarded  as  a much  more  serious 
intoxication  than  that  resulting  from  morphine. 

The  principal  phenomenon  by  which  we  might  distinguish 
cocainic  from  morphinic  insanity,  and  which,  according  to  iMagnan 
and  Soury,  would  be  the  predominating  feature,  would  consist  of 
cutaneous  parsesthesia,  accompanied  by  visual  hallucinations  of 
worms  and  insects,  or  by  false  judgments  as  to  microbes  in  the 
skin  all  over  the  body.  Hallucinations  and  deliria,  which  in  certain 
cases  are  somewhat  rudimentary,  and  need  not  compromise  the 
mental  structure  of  the  patient  to  any  marked  extent,  are  in  other 
instances  associated  with  otlier  hallucinations,  and  give  rise  to  a 
true  agitation  which  has  a certain  resemblance  to  delirium  tremens. 

The  cutaneous  hallucinations  giving  rise  to  judgments  of  worms 
and  other  small  animals  in  the  skin  are  not,  however,  characteristic 
of  cocainic  intoxication,  because,  independently  of  other  observa- 
tions, I have  met  with  them  typically  in  a case  of  uncomplicated 
insanity  from  morphine. 

In  the  gravest  cases  there  are  superadded  hallucinations  of  sight 
and  liearing,  which  are  of  rather  fearful  content,  and  pronounced 
agitation,  as  in  acute  sensory  insanity.  In  others  a true  hypo- 
chondriacal delirium  may  develop,  but  it  rarely  reaches  the  limits 
of  delirium  of  negation. 

The  cocainists  are  often  suspicious  and  querulous,  garrulous  in 

7/B 


COCAINIC  INSANITY 


779 


conversation,  and  proliferous  in  their  writing  (Erlenmeyer) ; later 
on  they  become  forgetful. 

The  mental  are  often  associated  with  somatic  phenomena,  such 
as  tremors,  tetaniform  states  (case  of  Chalmers,  da  Costa),  epilepti- 
form attacks,  rapid  emaciation,  and  even  collapse,  with  or  without 
ocular  phenomena,  such  as  diplopia,  amblyopia,  and  scotoma. 

Recovery  is  the  usual  issue  of  the  psychosis.  The  latter  is  not 
to  be  confounded  with  acute  poisoning  from  cocaine,  which  we 
cannot  discuss  here. 

The  therapy  is  symptomatic  (baths  and  tonics),  and  consists 
principally  in  gradually  breaking  off  the  drug  habit. 


CHAPTER  XXVIII 


CHLORALIC  INSANITY 

Rather  should  we^speak  of  chloralic  dementia  than  of  chloralic 
insanity.  As  a matter  of  fact,  it  is  very  rarely  that  we  have  pheno- 
mena of  true  insanity  as  a sequel  to  chronic  chloralic  intoxication. 
The  chloralists  are  neurastheniacs  or  ex-melancholiacs  who,  having 
been  subject  to  insomnia,  have  fallen  into  the  habit  of  taking  a 
dose  of  chloral  at  night  before  going  to  bed,  and  have  been  unable 
to  give  up  the  habit.  They  have  a real  dread  of  insomnia,  and 
take  this  chloral  in  doses  ranging  from  a very  small  quantity  to 
3 grammes  every  night.  In  the  long-run  they  suffer  more  frequent  ■ 
accessions  of  anguish,  lose  their  keen  and  ready  intelligence,  becom-  ; 
ing  torpid  and  somewhat  degraded.  Their  memory  is  weakened  ; 
along  with  the  attentive  capacity,  and  dulness  becomes  more  ! 
marked.  Meanwhile,  they  suffer  from  gastro-intestinal  disturbances  , 
and  become  paler  ; nutrition  fails.  In  rarer  instances  hallucinatory  ^ 
phenomena  supervene. 

It  is  a good  plan  only  to  use  chloral  very  rarely  as  a remedy  for 
the  insomnia  of  neurasthenia  and  states  of  depression,  because  the 
action  it  exerts  on  the  brain  does  not  contribute  to  raise  the  func- 
tional tone. 


CHAPTER  XXIX 


SATURNINE  INSANITY 

I Lead-poisoning  produces  phenomena  closely  resembling  those  of 
J alcoholic  intoxication.  Some  authors,  especially  in  France  (Regis), 
i even  speak  of  an  acute  and  subacute  psychosis  of  dementia  and  of 
i saturnine  pseudo-general  paralysis. 

I The  acute  variety  very  closely  resembles  the  delirium  in  alco- 
:|  hohsts.  It  is  preceded  by  headaches,  attacks  of  vertigo,  bad 
!!  humour,  intestinal  disturbances,  insomnia,  sometimes  by  somno- 
i lence.  Examination  of  the  urine  often  shows  the  presence  of 
I albumin.  These  phenomena  are  present  for  some  time  before  the 
:!  accession  announces  itself,  but,  should  the  attack  be  provoked  by 
l[  some  psychic  trauma,  it  may  come  on  without  being  preceded  by 
i|  prodromata.  Sleep  becomes  uneasy  and  disturbed  by  terrifying 
ij  dreams.  The  accession  bursts  out  in  the  form  of  sensory  insanity, 

|[  with  illusions  and  hallucinations,  generally  terrifying,  which  quickly 
« induce  in  the  patient  a keen  and  pronounced  agitation  with  aggres- 
sive tendencies.  The  face  is  red,  the  eyes  clear,  the  breath  foetid, 
the  attitude  hostile,  the  temperature  subfebrile.  The  patient! 
though  he  now  presents  a marked  and  characteristic  tremor,  is 
violent  and  obscene.  The  attack  lasts  one  or  two  weeks,  after 
li  which  sleep  returns,  the  agitation  ceases,  tranquillity  is  re-estab- 
I!  hshed,  the  hallucinations  disappear,  and  at  the  same  time  the 
i|  intellect  is  restored.  It  is  no  rare  thing,  however,  for  phenomena 
of  coUapse  and  even  death  to  occur  after  the  very  acute  phase  of 
I the  attack,  just  as  in  acute  delirium.  In  other  cases  the  acute 
|l  hallucinatory  phase  is  followed,  as  in  ordinary  sensory  insanity, 

■ by  a condition  of  stupor,  which  has  all  the  characteristics  of  the 
i stupidity  already  described,  with  the  addition  of  the  general  pheno- 
mena of  lead-poisoning  (bluish  line  on  the  gums,  tremors,  etc.). 

I ^ In  some  cases,  instead  of  sensory  insanity,  we  have  the  develop- 
iment  of  acute  melancholia,  with  features  of  hypochondriasis 
j accessions  of  anguish,  and  suicidal  tendencies. 

The  attack  of  saturnine  hallucinatory  insanity  may  be  followed 
by  slow  mental  enfeeblement  (secondary  dementia),  a condition 

781 


782 


PSYCHIATRY 


that  sometimes  is  even  primary,  and  is  an  effect  of  the  alterations 
induced  by  the  lead  in  the  structure  of  the  nerve-elements.  Some- 
times it  is  followed  by  a syndrome  closely  resembling  progressive  | 
paralysis.  This  condition,  pointed  out  by  Tanquerel,  and  con- 
firmed and  well  described  by  Delasiauve,  was  for  some  time  regarded  j 
as  true  progressive  paralysis  from  lead,  especially  by  Devouges,  | 
until  Regis,  who  was  able  to  follow  some  cases  and  verify  complete  | 
recovery,  distinguished  it  from  true  progressive  paralysis,  terming  ' 
it  saturnine  pseudo-general  paralysis. 

As  a rule,  the  commencement  of  this  paralytic  syndrome  is  not 
gradual  and  primary,  but  follows  upon  an  attack  of  acute  insanity, 
which,  as  soon  as  the  state  of  calm  is  established,  passes  into  a new 
phase,  manifesting  itself  with  the  gravest  characteristics  of  the  con- 
firmed stage  (Regis).  These  symptoms  are  mental  enfeeblement, 
as  in  paralytic  dementia,  tremors,  inequality  of  the  pupils,  impedi-  j 
ment  of  speech,  even  to  the  degree  of  unintelligible  muttering,  more  | 
or  less  grave  dementia,  brief  appearances  of  hallucinations  and  1 
deliria,  and  a diffident,  suspicious,  wicked  character. 

Even  when  the  mental  disturbance  (dementia)  seems  profound 
and  grave,  the  patients  after  a period  of  time,  generally  not  long, 
gradually  regain  their  mental  energy,  which  is  restored  to  its  former 
condition.  As  is  apparent,  this  syndrome  of  saturnine  dementia, 
according  to  some  authors,  differs  in  no  way  from  ordinary  pro- 
gressive paralysis,  except  as  regards  its  favourable  issue — complete 
recovery.  | 

I must  add  that  I have  not  had  any  case  under  personal  observa-  ; 
tion.  ; 

Sometimes  apoplectiform  attacks  occur,  followed  by  mental  '! 
bluntness  and  hemiplegia,  with  hemianaesthesia,  in  all  respects  ’i 
resembling  hysterical  anaesthesia.  It  is  not  improbable  that  these  , 
apoplectiform  attacks  are  due  to  the  albuminuria,  and  are  of  a 
uraemic  nature. 

The  simple  and  the  paralytic  forms  of  dementia  are  often  com-  . 
plicated  by  signs  of  cachexia  (cachectic  dementia).  ^ 

Pathological  Anatomy. — The  alterations  resemble  those  found  in  \ 

alcoholic  intoxication.  According  to  Lugaro,  who  has  investigated  ; 
the  subject  from  the  experimental  side  [Riv.  di  Patolog.  Nerv.  e <1 
Ment.,  1897),  they  consist  in  pulverization  of  the  chromatic  sub-  ; 
stance,  and  in  disappearance  of  the  fibrillar  structure  of  the  cell, 
with  swelling  of  the  protoplasm  and  shrinking  of  the  nucleus.  ^ 
These  alterations  are  much  more  evident  in  the  spinal  ganglia  than  ■ 
in  the  spinal  cord.  In  addition,  there  are  found  small  blocks  of  i 
coarsely  granular  yellow  pigment  in  the  cells  of  the  spinal  cord,  ; 
cells  with  irregular  ‘ contour,  and  deformity  of  the  protoplasmic 
prolongations.  These  lesions  are  met  with  in  the  cells  of  the  cere-  : 
bral  cortex,  along  with  vacuolization  of  the  protoplasmic  processes,  j 


SECONDARY  DEMENTIA 


7^3 


which  become  deformed.  In  cases  of  long  duration  lesions  are 
found  in  the  vessels  and  the  neuroglia, 
f; 

. Therapy.— The  therapy  is  symptomatic  as  regards  the  psychic 

■ -phenomena,  but  must  have  as  its  chief  aim  the  prompt  elimination 
of  lead  from  the  organism. 


■;  . APPENDIX 

' SECONDARY  DEMENTIA 

^ All  mental  affections  that  are  not  followed  by  recovery  terminate 
\ in  the  so-called  secondary  dementia.  This  condition  has  no  place 
if  in  our  classiiication,  because  it  is  not  a morbid  entity,  but  an  issue 
:|,  of  all  acute  and  chronic  mental  affections  not  followed  by  recovery. 
; Amongst  these  I must  make  particular  mention  of  mania,  melan- 
; cholia,  sensory  insanity,  and  epilepsy. 

j \Yhenever  one  of  these  maladies  pass  into  dementia,  the  funda- 
I mental  character  of  the  primary  affection  loses  its  keenness  \ the 
-i  false  mental  products  (deliria)  often  remain,  but  are  less  active, 
j finding  less  nourishment  in  a soil  which  no  longer  offers  elements 
^ to  sustain  them.  The  whole  morbid  personality,  even  when  re- 
stored within  certain  limits,  and  in  one  or  other  portion,  is  seen  to 
be  weakened,  with  limited,  sometimes  extremely  scant,  potentiality 
in  all  its  manifestations  and  in  all  the  directions  of  psychic  life. 

: The  perceptive  process  being  reduced  and  torpid,  the  intellectual 
: patrimony  diminished,  what  remains  is  so  inefhcient  and  of  such 
' small  utility  that  it  lacks  the  refreshing  influence  of  interest  which 
is  based  on  the  extinguished,  or  almost  extinguished,  emotivity  and 
■ affectivity ; the  dement  loses  all  capacity  to  display  any  efficacious 
) action  whatsoever  in  his  environment. 

^ In  general,  the  dement  is  in  part  what  he  was  when  sane,  with  a 
I mingling  of  the  products  of  the  malady,  which,  even  though  they 
1 also  be  reduced,  yet  give  their  stamp  to  the  enfeebled  personality, 
j Thus  the  melancholiac  will  continue  to  have  the  attributes  of 
, melancholia,  and  the  maniac  those  of  mania.  Under  the  melan- 
I cholic  aspect,  however,  there  no  longer  reigns  the  grief  that  first 
; determined  it,  and  the  slowness  of  ideas,  due  at  first  to  inhibition, 

: becomes  slowness  from  poverty  and  relaxed  associative  bonds, 
j The  melancholiac  who  formerly  suffered  much  and  attempted  to 
; commit  suicide,  now,  when  he  passes  into  dementia,  repeats  the 
I ^me  grievances  in  a stereotyped  manner ; but  he  no  longer  suffers, 

I or  suffers  rather  less  than  before,  and  makes  no  further  attempt  at 
f suicide,  except  in  the  case  where  the  suicidal  tendency  remains  as 
fj  a tic,  as  a blind  impulse  occurring  insistently  and  irresistibly,  even 


784 


PSYCHIATRY 


after  disappearance  of  the  cause  that  first  gave  rise  to  it  (cerebral 
automatism). 

The  deliria  sometimes  disappear,  more  often  they  remain,  so 
that  we  may  speak  of  a secondary  dementia  with  deliria  and  a 
secondary  dementia  without  deliria.  A certain  number  of  secon- 
dary dementias  with  deliria  may  be  called  secondary  paranoias. 
The  deliria  are  the  same  as  in  the  primary  affection,  being  simply  i 
continued  therefrom,  and  when  mental  erifeeblement  commences 
they  become  systematized.  The  patient  repeats  always  the  same 
delirious  ideas,  which  closely  resemble  those  of  paranoia,  more 
especially  when  of  hypochondriacal  or  persecutory  content.  It  is 
needless  for  me  to  enlarge  upon  this  subject  after  what  I have 
already  said  in  the  respective  chapters  on  mania  and  melancholia. 

Amadeo  and  Tonnini  advanced  good  arguments  in  support  of  the 
belief  that  this  form  of  secondary  paranoia  is  curable.  I am  con- 
vinced that  their  views  are  correct. 

Sometimes  the  mental  enfeeblement  is  only  apparent,  being  an 
effect  of  cerebral  exhaustion,  produced  in  its  turn  by  the  severity  of  j 
the  disease  and  its  cause  (intoxication).  There  is  no  doubt  that  the  | 
nutritive  reintegration  of  the  brain  in  some  cases  takes  place  slowly  ; | 
in  these  cases  the  brain  power  returns  by  degrees,  and  at  the  same  1 
time  the  deliria  gradually  disappear  (mediate  recovery).  ! 

It  is  certain,  however,  that  the  conception  of  secondary  paranoia  I 
was  of  considerably  greater  importance  so  long  as  sensory  insanity 
was  not  recognised  in  all  its  forms,  and  when  the  paranoid  and  the  ; 
melancholic  variety,  preceded  by  an  acute  sensory  delirium,  was 
mistaken  either  for  mania  or  melancholia.  Many  secondary  para-  j 
noias  correspond  to  the  paranoid  forms  of  sensory  insanity.  We  j 
need  occupy  ourselves  no  further  with  these  after  what  we  have 
already  written.  The  majority  of  dements  who  crowd  the  asylums 
are  supplied  by  sensory  insanity  of  one  or  other  form,  particularly  ! 
the  confusion al  and  the  paranoid.  I 

The  half  of  these  patients  who  do  not  recover  remain  in  the 
asylum  for  years  and  years,  presenting  always  the  same  fundamental  i 
features  of  the  primary  affection  (hallucinations,  deliria).  The  ! 
various  forms  of  acute  dementia  are  indefinitely  protracted.  We  ■ 
do  not  know  when  the  acute  phase  of  the  illness  ends  and  when  the  I 
chronic  period  of  incurable  dementia  commences.  Dementia 
prcecox  is  prolonged  and  continued  into  terminal  dementia.  No 
limit  can  be  laid  down  ; no  change  of  symptoms  indicates  the  passage 
from  the  one  condition  into  the  other,  save  in  some  cases  an 
improvement  of  the  nutrition.  Such  dements  remain  for  years  in 
the  conditions  described,  with  few  and  insignificant  modifications. 

Epilepsy  provides  another  contingent  of  secondary  dementias. 
\Mien  the  epileptic  convulsions  are  frequently  repeated,  and  par- 
ticularly when  followed  by  attacks  of  insanity,  all  the  more  if  these  ■ 
are  protracted,  the  mental  powers  all  become  enfeebled.  Such  | 


SECONDARY  DEMENTIA 


785 


patients,  whilst  they  show  great  reduction  of  the  perceptive  capacity, 
narrowing  of  the  ideative  field,  uncertainty  and  lapses  of  memory 
in  the  most  varied  forms  of  dysmnesia,  whilst  they  are  not  concerned 
about  their  present  state  or  their  future  welfare,  and  take  no  interest 
in  the  affairs  of  the  family,  are  yet  egoistic,  querulous,  impulsive, 
cynical,  and  wicked.  The  dementia  always  preserves  a part  of  the 
old  personality,  and  some  of  the  features  of  the  malady  that  gave 
rise  to  it. 

Sometimes  the  eonsecutive  mental  weakness  reveals  itself  only 
in  diminution  of  the  will-power.  The  mental  patrimony  is  not 
essentially  diminished,  and  the  normal  sentiments  seem  restored  ; 
but  the  whole  mental  life  has  become  more  feeble,  a true  interest  in 
things  is  lacking,  and  the  determinative  power  is  very  defective. 
Such  patients  have  no  depth  of  thought,  sentiment,  or  action. 
There  are  dements  in  whom  mental  enfeeblement  is  not  readily 
noticed,  even  though  it  be  well  marked.  It  is  not  easy  to  estimate 
the  loss  that  has  taken  place  without  taking  into  account  the  intel- 
lectual vigour  and  the  mental  patrimony  formerly  at  the  command 
of  each  individual.  Highly-cultured  and  talented  individuals  always 
appear  better  equipped  than  those  who  have  not  received  a good 
education  nor  moved  in  high  and  intellectual  circles.  In  such  cases 
it  is  necessary  to  collect  all  such  historical  data  as  enable  us  to  re- 
construct the  figure  of  the  psychic  personality  prior  to  the  malady, 
and  in  this  wa}^  we  shall  bring  into  evidence  the  losses  and  the  in- 
capacities, as  well  as  the  alterations  in  the  affective  states.  The 
man  who  used  to  take  an  interest  both  in  bis  own  and  other’s  affairs, 
who  played  an  active  part,  and  engaged  in  struggles  in  public  life, 
was  enterprising,  active,  restless,  who  was  concerned  about  his 
family,  the  health  and  the  economic  status  of  his  children,  now 
remains  apathetic,  indifferent,  undisturbed  by  the  course  of  affairs. 
The  harmony  of  the  human  senses  is  interrupted  tor  ever  ; in  his 
mind  there  no  longer  vibrates  and  trembles  any  high  sentiment  ; 
his  intellect  being  dull  and  feeble,  his  conversation,  when  he  is  at  all 
able  to  pronounce  his  words,  is  always  very  brief,  and  resembles 
the  stereotypic  repetition  of  a phonograph. 

Infantilism  is  manifest  in  almost  every  position  in  life,  belied 
only  by  the  changes  wrought  by  the  years  on  the  physiognomy  and 
on  the  body,  and  by  the  old  systematized  habits. 

In  the  graver  and  more  advanced  forms  the  incoherence,  often 
manifest  also  in  the  actions,  reaches  the  extreme  degrees  ; the 
thought  loses  its  syntactic  and  grammatical  form  (alogia,  akata- 
phasia) ; the  indifference  is  very  marked.  The  fall  of  the  mental 
edifice  is  complete,  but  the  ruins  that  remain  allow  us  to  judge 
whether  they  are  those  of  the  lordly  mansion  of  a well-nourished 
mind  or  of  the  lowly  hut  of  an  intellectual  starveling.  With  the  help 
of  these  ruins  and  the  stimuli  that  fall  from  the  outer  world  into 
the  still  warm  crucible,  the  dement  sometimes  forms  new  products 

50 


786 


PSYCHIATRY 


of  no  value,  often  rather  of  a negative  value,  and  therefore  hurtful.  | 
One  patient  many  years  demented,  being  very  quiet  and  allowed  to  ' 
go  about  by  himself,  conceived  the  plan  of  mounting  to  a roof  in  | 
order  to  reach  home,  and  did  not  picture  to  himself  the  interrupting  | 
spaces  between  the  roofs,  and  the  probability  of  his  being  precipi-  : 
tated  to  the  ground.  ; 

A great  number  of  patients  who  remain  massed  together,  as  the  | 
caput  moftuum  of  the  asylums,  dirty  when  not  attended  to,  solitary,  | 
collectionists,  given  to  squatting  on  the  floor  or  in  a corner,  to  | 
throwing  off  their  clothes  and  their  shoes,  to  soliloquy,  apathetic, 
or  subject  to  brief  phases  of  agitation  accompanied  by  animal- 
like cries  and  curses,  merely  represent  the  ruins  of  human  intelligence 
over  which  the  disastrous  storm  of  insanity  has  passed.  Until  a 
few  years  ago  it  was  thought  that  the  majority  was  derived  from  | 
mania  and  melancholia  ; to-day  we  know  that  only  a small  number 
belong  to  the  latter  psychosis,  a few  to  paranoia,  more  to  epilepsy, 
the  majority  to  sensory  insanity. 

Secondary  or  consecutive  dementia  has  an  anatomo-pathological 
substratum  more  serious,  more  evident,  and  we  may  also  say  less 
reparable,  than  that  of  the  acute  curable  diseases  from  which  it  is 
derived.  Here  we  have  to  deal  not  with  simple  chromatolysis,  such 
as  we  find  in  recent  forms,  but  with  a more  profound  degeneration 
of  the  nerve-cell,  and  especially  that  form  of  degeneration  represented 
by  yellowish  globules  of  the  same  size,  closely  packed,  of  a vitreous 
aspect,  collected,  as  a rule,  at  the  base  of  the  cell  or  near  the  nervciis  ‘ 
process  or  the  protoplasmic  prolongations,  or  even  in  other  parts  of ; 
the  cell — a degeneration  termed  by  Colucci  yellow  globular  degenera- ' 
tion  {Annali  di  Neurologia,  1897)-  It  is  a substitution  for  the  sub- 
stance of  the  cell,  not  only  for  the  Nissl  bodies,  but  also  the  reticular^ 
stroma.  In  addition  to  this  form  of  degeneration,  we  find  fattv! 
degeneration,  pigmentary  degeneration,  disappearance  of  the 
nucleus  (termed  also  homogeneization  of  the  nucleus),  partial  swel-  , 
lings  of  the  cell  or  of  the  protoplasmic  prolongations,  thickening^ 
of  these,  cellular  atrophy,  deformity,  necrosis,  and  vacuolization., 
x\ccording  to  Mondio  {Annali  di  Neurologia,  1897)5  degenerati\  e i 
process  affects  particularly  the  protoplasmic  prolongations,  and  tiie^ 
axis-cylinder  prolongation  at  a much  later  stage,  or  to  a less  extent. .. 
There  is  no  doubt  that  in  secondary  dementia  it  is  the  neuro-fibrillar  l\ 
network  that  is  chiefly  injured  ; in  this  case  we  get  a true  irreparable 
dissolution  of  the  cell. 

Lying  amidst  more  or  less  profoundly  altered  cells,  we  find  many 
others  presenting  a normal  appearance.  As  a rule,  there  is  also  an 
accompanying  increase  of  neuroglia  ; here  and  there  the  \ essels  are 
sclerosed.  Spinal  lesions  are  not  wanting. 

Secondary  dementia  is  incurable  ; it  is  often  progressive.  ae  ^ 
degeneration  of  the  cortical  cells  is  followed  by  other  degenerati\e 
processes— in  the  liver,  kidneys,  heart,  gastro-intestinal  canal,  etc.  | 


^ SECONDARY  DEMENTIA  787 

[ Those  patients  who,  at  an  early  stage  in  their  slow  passage  into 
I dementia,  show  diminution  of  the  affective  excitability  and  a return 
i to  health,  with  improved  colour  and  increase  in  weight,  break  down 
j in  the  long-run,  and  often  become  hydrsemic  ; signs  of  spinal  de- 
generation,  with  spastic  paraparesis  and  sometimes  parenchymatous 
I neuritis,  next  appear. 

It  is  unnecessary  to  lay  down  any  line  of  treatment  in  cases  of 
t dementia.  It  is  well,  however,  to  recognise  the  fact  that  many 
dements  may  be  restored  to  a personality  which,  while  certainly 
reduced,  is  yet  fairly  well  co-ordinated,  and  may  be  of  some  service 
within  the  narrow  limits  of  asylum  life.  A series  of  observations 
I has  convinced  me  that  in  many  cases  the  mental  destruction  is  not 
so  complete  as  it  seems.  It  often  appears  to  me  to  resemble  a deep 
! mental  lethargy,  or  something  buried  alive.  Training  and  re-educa- 
I tion  restore  vigour  to  many  of  the  elements  of  mental  life,  which  may 
' flourish  again  in  some  useful  work  or  in  some  new  adaptation.  Many 
of  the  dements  who  are  employed  on  the  farms  or  in  the  offices  of  the 
asylums  have  proved  capable  of  re-education  to  a serviceable  life, 
modffied  according  to  individual  circumstances,  no  matter  what  their 
previous  condition  ; with  good  attention,  regulation,  and  supervision, 
they  give  partial  compensation  for  their  cost  of  maintenance. 


CHAPTER  XXX 


THIRD  GROUP— DEMENTIA  PARALYTICA 

(Progressive  Paralysis,  General  Paralysis,  etc.) 

Paralytic  dementia,  one  of  the  gravest  of  diseases,  occurs  frequently 
in  some  countries,  and  is  characterized  anatomically  by  a progressive 
degeneration  (according  to  some,  by  a slow  inflammatory  process), 
which,  commencing  in  certain  nervous  regions,  in  its  ulterior  de- 
velopment invades  the  entire  nervous  system.  Clinically,  it  is  recog- 
nisable by  a progressive  decadence  of  all  the  nervous  functions — 
psychic,  senso-motor,  and  trophic,  up  to  the  extinction  of  life. 

Symptomatology . — The  mode  of  onset  varies  considerably,  and  ’ 
the  multiplicity  of  symptoms  is  such  as  sometimes  to  lead  the 
clinician  astray.  The  disease  is  always  recognisable  at  a more  ' 
advanced  stage. 

Given  the  improper  uses  which  paralytics  may  make  of  their 
own  and  others’  means  at  the  initiation  of  the  disease,  and  the 
dangers  to  which  their  disordered  and  anomalous  conduct  exposes  | 
them,  it  becomes  the  task  of  the  clinician,  as  obligatory  as  it  is  difh-  , 
cult,  to  diagnose  the  malady  at  its  commencement,  so  that  the  ^ 
social  relations  of  the  patient  may  be  regulated  at  an  advantageous , 
time,  and  that  the  patient  be  brought  under  the  influence  of  those  | 
methods  of  treatment  that  only  then  are  capable  of  diminishing^ 
the  intensity  and  checking  the  rapidity  of  its  course.  •! 

Of  the  different  modes  of  onset  of  the  disease,  the  four  most 
frequent  and  most  readily  recognisable  are  : 

I.  In  one  group  there  is,  as  a rule,  exaltation  of  the  various 
psychic  activities.  The  individual  becomes  more  enterprising,  ; 
more  active,  more  restless.  His  desires  become  more  urgent  and  ! 
numerous,  more  irresistible  and  excessive  ; his  objectives  more 
grandiose,  his  projects  vaster.  He  jumps  to  bold  conclusions.  ; 
The  day’s  labour  no  longer  satisfies  him  ; he  gets  up  at  unusual  | 
hours  in  the  night-time,  and  writes  and  calculates.  He  seeks  out 
his  friends  oftener  than  before,  expounds  to  them  his  plans,  and  | 

788  i 


DEMENTIA  PARALYTICA 


789 

invokes  their  co-operation,  frequently  obtaining  it.  Absorbed  in 
the  mirage  of  his  vast  projects  and  his  great  social  relations,  he  no 
longer  adapts  himself  to  the  circumstances  of  the  everyday  family 
life  as  in  the  past,  and  becomes  less  tolerant  of  opposition.  By 
degrees  the  apperceptive  process  weakens.  The  paralytic  pursues 
his  dreams.  He  conceives  some  foolhardy  undertaking,  into  which 
he  throws  himself  without  reflecting  upon  the  means  to  be  em- 
ployed, without  pondering  the  matter  in  his  mind,  without  fore- 
seeing the  obstacles  that  must  necessarily  arise,  often  without  a 
well-defined  notion  of  the  end  he  has  in  view. 

The  business  man  lays  in  large  stocks  of  goods,  and  cannot  fulfil 
his  obligations  ; the  medical  man  is  on  the  eve  of  discovering,  or 
has  discovered,  a specific  for  the  cure  of  one  of  the  gravest  and 
most  incurable  diseases,  and  will  become  a millionaire  ; the  en- 
gineer has  already  devised  a new  railway  scheme  : it  will  meet  with 
the  approval  of  the  Government,  the  funds  will  be  forthcoming, 
and  a large  company  will  be  formed  ; the  small  proprietor  sells 
his  modest  establishment,  the  sole  resource  of  his  family,  because 
he  must  purchase  a large  estate,  the  returns  from  which  will  allow 
him  to  maintain  horses  and  carriages.  Meanwhile,  each  of  them 
lives  in  a much  mere  stylish  manner  at  home  ; the  table  is  more 
sumptuous  than  formerly — rare  and  costly  dishes  are  added  to  the 
modest  menu,  and  wines  and  liquors  flow  more  freely  than  before. 
All  is  merriment,  but  only  to  be  followed  very  soon  by  the  most 
implacable  delusion.  The  poor  Neapolitan  carries  his  dream  into 
effect.  Having  no  faith  in  his  own  activity,  he  puts  his  trust  in 
lotteries,  for  fortune  will  in  the  end  smile  upon  him.  He  is  now 
certain  of  securing  a big  prize,  and  with  all  confidence  and 
certainty  he  risks  the  little  he  has,  or  what  he  derives  from 
pawning  his  few  pieces  of  furniture,  in  buying  a number  of 
coupons  for  his  family  of  four  persons. 

The  paralytic  belonging  to  this  group  is  more  expansive,  generous, 
and  happy ; sometimes  he  is  lively  and  witty.  He  is  irritated  by 
the  least  opposition,  and  breaks  out  into  excesses,  but,  on  the  other 
hand,  is  fonder  of  his  wife  than  formerly.  Embraces  become  more 
frequent.  ‘ He  never  enjoyed  such  excellent  health  ; not  even  in 
his  youth  did  he  feel  so  strong  as  now.’ 

Amidst  this  functional  hyperactivity,  more  apparent  than  real, 
we  perceive  some  characteristic  signs  that  may  from  the  very  outset 
suggest  to  our  minds  the  disease  which  later  will  reveal  its  cruel 
and  relentless  nature.  These  fundamental  notes  consist  in  the  real 
weakness  of  the  various  psychic  manifestations,  and  in  the  complex 
degradation  of  the  intellect  and  affections,  ill  concealed  by  the 
hyperactivity  described  in  the  excessive  boldness  of  his  under- 
takings. We  readily  perceive  a contradictory  superficiality  of 
judgment,  a puerility  of  the  notions  and  a disorder  of  the  conduct. 
A literary  person  commences  to  attribute  very  great  value  to  the 


790 


PSYCHIATRY 


work  he  published  a few  years  or  several  months  previously.  He 
believes  it  superior  to  all  the  literary  productions  of  the  period, 
expects  from  it  very  great  triumphs  and  immense  profits.  He 
conceives  not  merely  one  but  several  works,  ‘ which  will  all  have  a 
surprising  effect.’ 

Whilst  nothing  yet  exists  of  the  work  announced,  the  author 
straightway  embarks  upon  a scheme  for  another,  the  plot  of  which  he 
likewise  announces.  His  mind  is  occupied  only  with  new  projects, 
and  with  castles  in  the  air.  He  does  not  notice  the  material  that 
he  lacks.  In  other  instances,  however,  he  actually  sets  to  work 
with  unaccustomed  ardour.  He  does  not  sleep ; he  writes  and  re- 
writes in  large  scribbling  diaries  that  generally  make  the  most 
decided  contrast  to  the  bombastic  announcement  first  made. 

The  paralytic  writes  and  expounds  projects  and  enterprises  just 
as  his  unbridled  and  unruly  fancy  suggests  them  to  his  conscious- 
ness, and  whilst  he  promises  himself  immense  profits  from  his 
negotiations,  etc.,  it  is  easily  seen  that  he  is  incapable  of  orientating 
himself  in  his  environment,  in  which  he  moves  like  one  who  dreams, 
and  that  he  arrives  at  inferences  without  premises,  at  conclusions 
that  lead  to  disastrous  conduct.  Not  a few  links  are  wanting  in 
the  connecting  chain  of  his  thoughts,  which  often  lack  any  founda- 
tion in  fact. 

It  is  as  if  centripetal  rays  passed  through  a system  of  lenses 
which  projected  into  the  field  of  perception  an  enlarged  image, 
which  gives  unusual  incentive  to  the  mechanism  of  conclusion.  • 
Thus  it  is  that  the  paralytic  has  a foretaste  of  wealth,  luxury,  and  - 
pleasure,  and  though  he  has  not  yet  obtained  any  of  the  results  i 
he  dreamt  of,  he  rises  heedlessly  to  the  level  of  that  future  grandeur,  ' 
and  inconsiderately  squanders  all  he  possesses,  ruining  his  own  and 
his  family’s  interests,  and  often  going  through  considerable  for-  ' 
tunes. 

On  every  attempt  to  reason  with  him  he  shows  his  weakened 
judgment,  and  the  exalted  sentiment  of  his  personality  and  capacity,  , 
as  well  as  his  intolerance  of  opposition.  Woe  to  him  who  places  : 
obstacles  in  the  way  of  the  patient  in  this  stage,  or  who  attempts  | 
to  make  him  understand  the  irrational  character  of  his  assertions  i 
and  deeds!  He  then  loses  all  sense  of  propriety,  pours  out  invec-  | 
tives  against  everyone,  forgetful  and  unheeding  of  the  proprieties  \ 
and  expediencies  which  he  formerly  carefully  observed. 

Parents,  formerly  very  affectionate,  neglect  their  family  ; ex- 
emplary husbands  give  themselves  up  to  amours,  and  without 
shame  or  reserve  visit  the  houses  of  prostitutes. 

Those  who  formerly  were  jealous  of  all  the  most  delicate  social 
conventionalities  now  continually  freque*nt  resorts  of  evil  repute,  and 
use  trivial  and  obscene  language.  Should  they  find  themselves  in 
a company  of  friends  amongst  whom  are  ladies,  amidst  general 
consternation  they  address  to  the  ladies  words  that  are  unusually 


DEMENTIA  PARALYTICA 


791 


gallant  and  even  lascivious.  There  is  generally  a more  or  less  marked 
loss  of  moral  sentiment,  of  shame,  and  of  the  sense  of  decency. 
The  character  changes  with  the  greatest  facility,  because  the  con- 
ventional scruples  of  society  are  negligible  features  of  their  mind. 

To  this  there  is  added  very  early,  sometimes  even  before  these 
changes  are  noted,  loss  of  memory. 

The  amnesias  and  the  change  of  character,  not  so  evident  in 
the  early  stage  as  to  attract  the  attention  of  their  families  and  their 
friends,  but  of  no  small  value  for  the  clinician,  put  us  on  our  guard 
as  to  the  true  nature  of  the  disease.  Sometimes  we  have  to  deal 
with  persons  occupying  very  responsible  positions,  who  in  the  past 
have  been  very  attentive,  and  now  readily  forget  matters  of  which 
they  had  hitherto  been  very  mindful,  matters  whose  accomplishment 
had  become  a habit.  Important  business  appointments  are  no  longer 
fulfilled,  promised  medical  visits  to  patients  and  families  are  not 
paid,  discussions  in  tribunals  are  completely  forgotten,  or  it  may 
be  that  the  key  of  the  safe,  formerly  guarded  with  the  utmost  care, 
is  left  in  the  lock.  Names  of  friends  and  close  acquaintances  may 
no  longer  be  remembered ; the  patient  mixes  dates,  facts,  and  pro- 
mises. When  he  writes  he  leaves  out  letters  or  syllables  in  the 
formation  of  words,  or  entire  words  in  the  composition  cf  phrases. 

Meanwhile,  the  organic  desires  are  also  often  increased  in  in- 
tensity. We  have  already  remarked  how  paralytics  abandon  them- 
selves more  readily  or  rashly  to  sexual  pleasures.  At  the  same 
time,  they  often  eat  and  drink  more  than  ever  before,  with  these 
excesses  hastening  the  onward  march  of  the  disease. 

Insomnia  is  frequent,  and  sometimes  is  painfully  felt  by  the 
patient.  It  is  one  of  the  few  things  of  which  he  complains,  though 
!^ometimes  he  turns  it  to  some  account,  inasmuch  as  it  drives  him 
to  that  active  or  restless  life  manifested  particularly  at  night-iime, 
which  always  hastens  the  development  of  the  disease. 

It  sometimes  happens  that  during  a lucid  interval  or  a period 
cf  depression  the  patient  becomes  painfully  conscious  of  his  psychic 
alterations,  and  especially  his  mental  insufficiency,  and  he  then 
seeks  the  assistance  of  the  physician.  This,  however,  is  only  a 
fleeting  reawakening.  For  the  most  part  the  patient  betrays  an 
exaggerated  sense  of  well-being.  Never  has  he  known  himself  to 
be  so  strong  as  now,  never  before  has  he  been  able  to  undergo  such 
intense  fatigue,  nor  has  his  intellect  ever  been  so  ready  and  certain. 
In  reality,  however,  the  same  enfeeblement  that  has  overtaken  his 
psychic  activities  is  found  in  his  greatly  diminished  muscular  power. 

Progressive  paralysis  may  apparently  commence  with  an  attack 
of  acute  delirium  (cases  of  Zacher),  which  in  this  case  also,  as  in 
acute  primary  delirium,  is  determined  by  an  infective  agent,  which 
breaks  the  insidious  advance  of  the  paralysis.  We  may  note  also 
the  passage  of  the  mild  maniacal  form  into  the  typical  variety, 
often  resembling  grave  mania.  These  accidents,  however,  do  not 


792 


PSYCHIATRY 


to  any  great  extent  increase  the  difficulty  in  diagnosis,  when  we  ‘ 
take  into  account  the  mode  of  onset  of  the  disease  and  its  somatic 
features. 

The  condition  described  ma}'  be  followed  by  a progressive  ; 
amelioration,  or  a truce  of  longer  or  shorter  duration,  after  which  the  | 
features  of  dementia  or  the  deliria,  or  both  together,  become  more 
pronounced.  The  patient’s  condition  is  aggravated  : the  association 
of  ideas  becomes  ever  less  logical;  the  inhibitory  powers  become  i 
continually  weaker ; every  new  perception  is  incomplete,  and  does 
not  add  to  the  intellectual  capital  of  the  paralytic.  The  memory  I? 
becomes  ever  more  unfaithful  and  lacunar  ; he  mixes  facts,  dates, 
places,  and  persons  with  whom  he  was  formerly  familiar,  forgets  | 
their  names,  and  ascribes  to  one  or  other  characteristics  that  have  no  i 
existence  or  have  reference  to  other  times  and  other  persons  ; if  he 
writes,  he  omits  letters,  syllables,  whole  words,  and  wanders  from  the 
point.  Altogether  we  notice  a progressive  loss  of  former  acquisi-  ‘ 
tions,  dissociation  and  disgregation  of  the  personality,  and  on  this  ■ 
soil  the  delirium  now  flourishes  and  reaches  its  greatest  intensity. 

2.  The  second  variety  is  characterized  by  progressive  depression 
of  all  the  mental  faculties.  , The  aptitude  for  work  becomes  gradually 
diminished  ; the  individual  often  complains  of  feeling  tired  and 
worn  out  ; the  attention  is  weaker,  the  powers  of  comprehension 
and  judgment  are  diminished  ; the  patient  gradually  becomes  more 
incapable  ; not  only  are  new  acquisitions  difficult  for  him,  but  even 
those  previously  acquired  become  lost.  This  threatening  initial 
mental  decay  is  generally  noticed  very  early  by  the  patient,  who  ] 
becomes  alarmed  thereat,  although  in  other  instances  he  progresses 
unconsciously  to  the  ulterior  stages  of  the  malady. 

There  is  no  intellectual  and  affective  function  that  is  not  over-  s 
turned  in  this  decline  and  fall  of  the  personality. 

The  loss  of  memory  is  marked,  the  memories  of  the  past  being 
somewhat  more  resistant  than  those  that  refer  to  very  recent  times  ; ; 
in  any  case,  however,  we  have  always  to  do  with  faint,  uncertain,  < 
fragmentary  reminiscences,  without  precise  determination  of  time,  ; 
place,  or  perfon. 

The  ideative  content  becomes  steadily  more  impoverished  and  ^ 
baroque,  and,  owing  to  feeble  associations,  moves  in  always  more  'j 
restricted  spheres.  No  delirious  ideas  exist.  ! 

Along  with  the  mental  decadence,  the  psychic  personality  becomes 
altered  in  all  its  attitudes.  For  the  most  part  the  patient  is  dull  [ 
and  somewhat  preoccupied  ; he  knows  he  is  not  what  he  once  was,  but  i 
does  not  understand  the  change  that  has  taken  place  in  him.  The  | 
mental  tone  is  variable,  so  that  we  often  find  superimposed  on  the  | 
sad  face  an  infantile  smile  or  a sign  of  good  humour,  whilst  he  spends 
his  days  more  or  less  in  apath}^  By  degrees  he  becomes  more  in- 
different towards  his  friends  and  family,  takes  no  interest  in  the 
domestic  management,  neglects  the  more  important  business,  is 


DEMENTIA  PARALYTICA 


793 


inattentive,  dazed,  and  not  easily  moved  ; his  physiognomy  has  lost 
its  wonted  lively  expression. 

As  may  readily  be  judged,  this  form  has  many  points  in  common 
^ with  neurasthenia  and  melancholia  ; but  the  rapid  progress  of  the 
dementia  and  the  somatic  facts  accompanying  or  appearing  soon 
after  the  onset  of  the  disease,  above  all,  the  disturbances  of  speech, 
guard  us  from  error.  There  are  cases,  however,  which  for  some  years 
present  no  other  feature  than  the  syndrome  of  neurasthenia— a 
feeling  of  malaise,  great  preoccupation  about  the  personal  health 
and  prevalence  of  hypochondriacal  ideas,  dread  of  falling  ill,  de- 
spondency, and  often  also,  along  with  this  syndrome,  severe  cephal- 
algia and  impotence.  It  may  be  impossible  to  detect  any  somatic 
sign  of  real  seme io tic  value  ; doubt  arises  from  the  progressive  nature 
of  the  neurasthenic  mental  decadence. 

3.  In  the  third  group  the  malady  commences  with  somatic 
symptoms,  or  at  least  a predominance  of  these,  whilst  the  mental 
disturbances  are  much  less  prominent  or  very  rudimentary.  These 
patients  commence  to  notice  various  qualitative  disturbances  of 
cutaneous  sensibility,  as  in  tabes  dorsalis  ; they  suffer  from  head- 
aches, neuralgias,  and  sometimes  ophthalmic  hemicrania  long  pre- 
cedes the  illness  (Charcot,  Fere,  Perinaud).  The  most  frequent  and 
characteristic  symptom,  however,  is  defect  in  expression  of  thought, 
whether  by  speech  or  writing.  At  first  the  patients  feel  a greater  re- 
sistance, as  It  were,  in  the  formation  of  articulate  sounds,  and  this 
disturbs  them  and  preoccupies  their  minds.  Th  en  commences  a certain 
slurring  m the  pronunciation  of  some  syllabic  sounds,  especially  the 
a la  s,  dentals,  and  palatals,  as  though  due  to  diminished  force  ; 
or  an  mco-ordmation  which  generally  alters  the  constitution  of  the 
more  complex  sounds,  and  gradually  involves  the  simpler,  according 
as  one  or  other  part  of  the  articulatory  apparatus  is  invaded  by  th 
degenerative  process. 

The  simple  slurring  mentioned  above  attains  gradually  to 
complete  disappearance  of  certain  articulate  sounds  or  a vocalized 

stammering  that  has  no  more  than  the  semblance  of  articulate 
sounds. 

We  have  to  deal  with  partial  and  temporary  paresis  or  paralysis 
01  certain  muscles,  with  the  inopportune  and  sometimes  sudden  and 
capncrous  intervention  of  certain  other  muscles,  with  unequal  dis- 
ribution  of  nervous  energy,  with  the  increased  time  required  by  the 
latter  to  traverse  obstructed  or  collateral  paths,  giving  rise  to  dis- 
urbance  of  the  function  of  one  or  other  part  in  particular  of  the 
apparatus  of  phonation,  respiration,  and  articulation,  which  concur, 
in  a given  space  of  time  and  with  a given  amount  of  energy, 
owards  the  expression  of  thought  and  speech. 

We  pt  various  articulatory  disorders  of  speech.  The  so-called 
radylaha  is  where  the  speech  is  slow  and  hesitating  ; the  syllabic 
soun  s aie  fully  articulated,  but  are  detached  from  one  another, 


794 


PSYCHIATRY 


and  there  is  a longer  interval  of  time  between  them,  as,  for  example,  I; 
fa-mi-ly.  In  most  instances,  however,  this  disturbance  is  not  the  | 
only  one  ; the  sounds  may  be  softened  or  otherwise  altered,  or  they  j 
may  be  tremulous,  or  the  vowel  of  one  syllable  is  dragged  out  till !' 
it  reaches  the  following  syllable — e.g.,  f-a-a-a-mi-i-i-i-ly-y.  Some- 1 
times  the  syllabic  sounds  constituting  a word  are  reversed  ; the  | 
various  syllables  are  pronounced  in  a position  different  from  what  i 
they  would  have  in  the  correct  formation  ; or  the  vowel-sound  alone  : 
of  each  syllable  may  be  reversed — e.g.,  wolling  hirse,  instead  of 
willing  horse — giving  a kind  of  paraphrasia  that  goes  by  the  name  of 
syllable -stumbling.  This  syllabic  transformation  is  often  of  such  a 
degree  that  the  speech  becomes  quite  unintelligible  ; it  is  the  most 
frequent  defect  of  speech  at  the  commencement  of  progressive 
paralysis,  and  appears  to  depend  upon  a disturbance  in  the  ideative  | 
held  from  defective  attention,  rather  than  on  a true  disorder  of  i 
articulation.  i 

In  addition  to  these  disturbances,  we  meet  with  lisping,  which 
consists  in  this,  that  at  the  moment  of  expiration  the  function 
of  the  expiratory  muscles  is  inhibited,  and  substituted  by  that  of  the 
inspiratory  muscles.  We  thus  get  an  interruption  in  the  act  of  con- 
necting the  vowel  to  the  consonant  : expiration,  which  should  bei 
co-ordinated  with  the  movements  of  phonation  and  articulation,  | 
is  substituted  by  an  inspiration  for  the  most  part  partial  and.j 
momentary.  j 

Sometimes  there  is  a spasmodic  condition  resulting  in  an  explo- 
sive formation  of  sounds,  giving  rise  to  the  so-called  scanning  or; 
staccato  speech,  with  all  the  intermediate  forms  up  to  stammering,  i 
which  in  this  case  has  by  no  means  the  same  significance  as  the  spas- ^ 
modic  laloneurosis  known  by  that  name.  All  these  disorders  may'j 
occur  singly  or  be  associated  in  the  same  patient,  and  as  they| 
advance  language  becomes  reduced  to  a string  of  unintelligible  | 
sounds. 

In  rare  cases  we  meet  with  the  temporary  disturbances  of  speech' 
noted  by  Konig,  and  consisting  either  in  tonic  spasms  of  the  muscles| 
of  speech  or  of  a momentary  pause,  during  which  the  muscles  of  thei 
lip  are  seen  to  move,  but  the  patient’s  efforts  to  speak  are  in  vain.} 
After  a few  seconds  he  commences  to  falter,  and  then  regains  hisi 
normal  speech.  During  the  pause  the  verbal  images  and  the  com- 
prehension remain  normal. 

The  disturbances  of  speech,  and,  in  a minor  degree,  some  altera- ; 
tion  in  the  timbre  of  the  voice,  often  constitute  the  first  symptoms 
of  progressive  paralysis,  when  all  the  morbid  psychic  phenomena! 
are  absent  or  incapable  of  detection. 

Paralytics  have  often  a dim  consciousness  of  these  disturbances,! 
and  at  intervals  become  concerned  about  them.  Syntactic  andj 
grammatical  errors  commence  to  appear  in  their  conversation  ; I 

phrases  are  left  unfinished  ; there  is  rapid  passage  from  one  order  of  j 

i 


DEMENTIA  PARALYTICA 


795 


ideas  to  another,  or,  though  there  may  be  a complete  conception  to 
express,  they  fail  from  time  to  time  to  find  the  corresponding  words 
and  resort  to  circumlocution.  In  order  to  appreciate  properly  the 
extent  of  the  disturbance,  it  is  necessary  to  know  the  previous 
degree  of  culture  of  the  patient. 

The  same  disturbances  are  observed  in  the  writing  ; it  is  slower, 
uncertain,  and  unequal.  The  handwriting  itself  presents  new  irregu- 
larities ; the  strokes  are  unequal,  tremulous,  and  in  some  parts  zig- 
zag, while  their  sloping  varies  considerably  ; there  is  exchange  of 
vowels,  substitution  of  consonants,  syllables  or  words  half-com- 
pleted. At  the  same  time  there  are  noticed  grosser  grammatical 
errors,  though  not  till  a later  period  do  we  find  dyslogic  disorders. 
Very  cultured  persons  commence  to  fall  into  frequent  errors  in 
spelling  ; they  are  no  longer  apt  in  the  grammatical  inflection  of 
words,  particularly  verbs. 

With  the  disturbances  of  speech  are  associated  other  somatic 
features,  such  as  tremors,  disorders  of  innervation  of  the  pupils, 
or  abolition  of  the  tendon  reflexes,  and  disturbances  of 
sensibility.  This  symptomatic  complex,  which  in  many  cases  may 
occur  by  itself  for  a time,  would  constitute  what  might  well  be 
called  the  somatic  form  of  progressive  paralysis.  It  is  not  that 
psychic  disturbances  are  entirely  wanting  in  this  variety,  but  that  in 
the  early  stages  they  are  less  evident.  There  is  generally  a depressed 
state  of  mind,  an  unwonted  slowness  of  the  psychic  processes,  a dim 
presentiment  of  being  threatened  by  some  disease,  and  an  effort  to 
hide  the  deficiency  of  which  they  are  already  conscious.  The  pre- 
cautions they  take  to  conceal  their  disturbances,  especially  of  speech 

in  this  respect  often  appearing  childish — the  pretended  gaiety  that 
some,  particularly  very  young  patients,  assume,  and  the  false  state- 
ments as  to  their  health  and  well-being,  are  in  open  contrast  with 
their  mental  preoccupation.  Meanwhile,  we  note  a ready  distrac- 
tion, listlessness,  negligence,  low  spirits,  a certain  lack  of  interest 
in  anything  they  do,  affective  irritability,  and  exaggerated  emotivity. 
Disorders  in  the  sexual  sphere  are  more  pronounced  in  this  class 
than  in  the  other.  Impotence  often  precedes  the  disease  for  two, 
three,  or  five  years.  From  time  to  time  the  ideative  process  is 
besieged  by  sexual  obsessions,  and  the  idea  and  desire,  irritated 
and  rendered  more  obstinate  by  repeated  failures,  instigate  to 
fresh  attempts  that  are  always  unsuccessful,  and  attended  with 
greater  damage  to  the  nervous  system.  At  one  time  the  defect 
consists  in  an  erotic  orgasm,  at  another  in  feeble,  insufficient,  or 
totally  absent  erection,  or,  again,  in  too  ready  ejaculation.  This 
often  constitutes  the  greatest  torment  of  these  patients  before  the 
onset  of  the  other  symptoms  we  have  mentioned.  In  many  cases 
the  tabetic  syndrome  long  precedes  the  attack. 

4.  In  the  fourth  group  we  have  individuals  who  have  always 
enjoyed  very  good  health. 


796 


PSYCHIATRY 


Some  vertigo,  some  fleeting  confusion,  sometimes  headache,! 
such  as  a feeling  of  weight  or  fulness  in  the  head,  and  attacks  of 
ophthalmic  hemicrania— these  constitute  all  that  we  can  gather  of 
the  history  of  the  commencement  of  the  disease.  In  other  cases 
the  premonitory  symptoms  consist  in  an  unwonted  affective  excita- 
bility, irascibility,  an  inner  restlessness,  an  inexplicable  discontent, 
symptoms  to  which  even  the  expert  clinician  can  assign  no  decided 
diagnostic  value.  One  day,  however,  the  patient  is  struck  down| 
by  either  an  apoplectiform  or  an  epileptiform  attack.  i 

When  the  attack  is  over  there  often  remains  a restriction  of  the! 
intellectual  and  affective  field,  but  cases  are  not  wanting  in  which 
we  get  a complete  restoration. 

After  several  weeks  or  months,  sometimes  even  a year,  when 
everything  leads  to  the  belief  that  all  danger  is  past,  the  attack 
is  repeated,  generally  with  increased  intensity.  The  subsequent 
psychic  depression  lasts  longer  on  this  occasion,  and  restoration 
is  more  difficult  and  also  less  complete. 

We  notice  a weakness  and  a want  of  determination  that  are 
quite  new.  The  mental  tone  is  depressed.  At  this  stage  we  may 
already  observe  somatic  and  psychic  signs  of  progressive  paralysis, 
but  it  frequently  happens  that  we  get  a comparative  restoration 
lasting  several  months  or  even  a year  or  so.  Later  on,  the  repeti- 
tion of  the  attacks  or  the  slow  development  of  the  symptomatic^ 
picture  of  paralytic  dementia  will  reveal  the  true  nature  of  the 
malady.  . ‘ 

These  four  modes  of  onset  of  progressive  paralysis  are  the  most 
frequent,  but  not  the  only  ones.  Sometimes  the  disease  commences^ 
as  an  acute  lypemania,  with  suicidal  tendencies  and  sitophobia,= 
or  as  acute  sensory  delirium.  In  rare  instances  it  begins  with 
delirium  of  persecution,  as  in  paranoia,  or  with  delirium  of  grandeur, 
without  any  premonitory  symptoms  (case  of  Hugues).  When  any, 
of  these  symptomatic  complexes  form  the  prelude,  simulating  a: 
simpler  form  of  psychopathy,  after  a longer  or  shorter  time,  accord-j 
ing  to  the  case,  the  symptoms  ameliorate  ; and  when  everything^ 
leads  to  the  hope  of  a very  early  recovery,  graver  phenomena  enter'; 
upon  the  scene.  ! 

The  distinction  between  the  symptomatic  groups,  justified  by  the  i 
mode  of  onset  of  the  disease,  is  not  so  manifest  at  a more  advanced  ^ 
stage.  It  is  not  that  there  do  not  then  exist  very  marked  differences  | 
in  the  various  cases,  and  perhaps  even  more  marked  than  those  ^ 
that  are  revealed  in  the  initial  phase  ; but  that  in  the  ulterior  course  i 
of  the  disease  we  meet  with  such  a confusion  and  concentration  of  i 
all  the  symptoms  thus  far  described  that  it  is  impossible  to  draw  j 
a rational  distinction  between  the  different  aspects  that  the  malady  j 
may  assume.  In  any  case,  no  practical  result  would  follow,  because,  | 
notwithstanding  the  views  of  Christian,  who  shows  great  concern  | 


DEMElStTIA  PARALYTICA 


797 


about  the  diagnostic  difficulties  in  paralytic  dementia,  no  true 
difficulty,  such  as  characterizes  the  often  insidious  commencement 
of  the  disease,  now  presents  itself  to  the  clinician. 

The  disease  assumes  a different  character,  according  to  the 
individual  organic  constitution,  the  particular  degree  of  culture 
previously  attained  by  the  patient,  and  the  individual  tendencies. 
Nevertheless,  there  are  always  characteristic  features  common  to 
all  the  varieties  of  dementia  paralytica  which  serve  as  a sure  guide 
to  the  diagnosis. 

The  progressive  diminution  of  almost  all  the  cerebral  powers 
has  now  reached  a very  significant  degree,  and  enables  us  to  differ- 
entiate the  disease  from  lypemania,  hypochondriasis,  mania,  and 
primary  hallucinatory  insanity. 

There  are  two  psychic  facts  that  are  of  the  utmost  importance  : 
one  is  essential— viz.,  dementia;  the  other  unnecessary,  but  very 
frequent— viz.,  delirium.  It  is  wrong  to  regard  the  dementia  as 
almost  a secondary  feature.  A scrupulous  examination  will  reveal 
its  existence  even  from  the  initiation  of  the  disease,  which  shows 
itself  by  psychic  decadence  in  all  the  manifestations  of  the  patient, 
both  within  the  small  sphere  of  domestic  life  and  within  the  large 
circle  of  the  social  relations. 

From  the  expression  of  the  physiognomy  to  the  character  of  the 
gaze,  from  the  latter  to  the  attitude  and  to  the  behaviour  in  the 
management  of  affairs,  everything  goes  to  prove  a state  of  mental 
decadence.  The  almost  set  expression  of  the  physiognomy,  the 
relaxed  features,  the  lifeless,  often  questioning  look,  the  mental 
slowness  or  incoherent  instability,  the  incapacity  to  pay  attention, 
the  considerable  or  slight  lapses  cf  memory  of  things  recent  and 
past,  the  superficialit3^  and  the  infantile  errors  of  judgment,  his 
childishness  shown  in  the  facility  with  which  he  is  controlled,' and 
the  possibility  of  making  him  believe  anything,  the  exaggerated  sense 
of  well-being,  without  the  proportionate  readiness  of  the  psychic 
processes,  which  we  meet  with  in  the  maniacal,  the  complete  abstrac- 
tion from  any  comprehension  of  his  real  position— all  these,  even 
at  the  commencement  of  the  malady,  when  characteristic  somatic 
disturbances  have  not  as  yet  appeared,  show  clearly  the  accompany- 
ing intellectual  degradation  in  all  its  phases  down  to  complete 
liquidation  of  the  psychic  personality. 

Deliria  arise,  and,  whether  expansive  or  depressive,  always  bear 
the  character  of  the  soil  in  which  they  have  developed,  and  cannot 
possibly  be  mistaken  for  other  similar  deliria. 

The  delirium  of  grandeur,  unless  in  some  rare  cases  where  it 
IS  the  first  thing  to  announce  the  appearance  of  the  disease,  may, 
m a manner,  be  regarded  as  the  continuation  of  that  first  variety 
which  we  have  described  in  speaking  of  the  initial  phases,  and  it 
gives  to  the  disease  the  character  of  a maniacal  form.  When  the 
personality  is  exalted,  the  sense  of  well-being  is  increased,  the  con- 


798 


PSYCHIATRY 


sciousness  of  the  patient  is  dysorientated,  and  the  soil  for  the  de-  | 
velopment  of  the  delirium  is  then  well  prepared. 

It  rapidly  loses  the  appearances  of  probability,  and  becomes  i 
unbounded,  paradoxical,  changeable,  and  stupid  in  form  and 
content.  If  the  patient  is  a business  man,  he  asserts  that  he  is  ; 
doing  a marvellous  amount  of  work,  that  he  will  open  the  largest  i 
warehouse  that  has  ever  existed,  that  he  has  already  greatly  in-  i 
creased  his  funds,  and  is  going  to  start  a great  industry,  etc.  Hardly  | 
a day  passes  but  he  affirms  that  he  has  ‘ acquired  all  the  factories  ! 
in  the  valley  of  the  Irno  that  he  is  now  a millionaire  ; that  he  owns  ■ 

‘ all  the  shops  in  the  Via  Toledo,  and  will  have  them  splendidly  i 
illuminated,  so  that  they  will  be  a more  beautiful  sight  than  any  ever  i 
witnessed  before.  There  will  be  splendour  and  fortune  for  everyone.’  ' 
From  this  stage  the  paralytic  passes  to  the  possession  of  billions, 
trillions,  etc.,  which  he  gives  away  to  the  first  one  who  makes  a good  ; 
impression  upon  him.  > 

A dealer  in  cattle  says  that  he  possesses  a hundred  oxen,  which 
will  forthwith  become  a thousand,  ten  thousand  ; then,  ‘ They  will 
be  yoked  to  as  many  carts  laden  with  precious  objects  later  on 
he  becomes  a king,  an  emperor,  etc. 

A lawyer  gives  lectures  on  the  best  mode  of  increasing  the  public 
wealth,  thereby  provoking  hilarity,  until  one  day  he  is  stricken  down 
by  an  apoplectiform  attack.  ! 

A poor  working  man  affirms  that  he  has  princedoms,  kingdoms, 
empires,  or  valleys  full  of  gold  ; another,  who  in  his  past  life  had 
tendencies  to  religious  practices,  asserts  that  he  is  the  Pope,  that  he  ! 
is  even  God,  above  God,  that  the  destinies  of  the  world  depend  on  j 
him,  that  he  can  make  the  stars  move  and  fall  down,  and  so  on.  | 

The  paralytic  is  astounding  in  the  excessive  nature  of  his  de-  | 
lirious  conceptions,  owing  to  which  he  becomes  generous  and  i 
prodigal  without  limit.  In  this  respect  he  shows  himself  absolutely 
lacking  in  judgment.  Let  him  only  be  encouraged  in  his  phan-  j 
tasmagorias,  and  he  will  offer  to  give  away  thousands,  millions,  to  I 
bestow  wealth,  happiness,  and  power  ; whilst  soon  after,  if  he  be 
contradicted,  he  will  threaten  one  with  annihilation. 

Such  patients  squander  large  sums  of  money  in  dinners  and  j 
feasting  with  acquaintances  and  even  strangers.  Even  in  the  j 
asylums  they  continue  to  give  invitations.  It  often  happens  that  | 
during  the  medical  visit  a paralytic  comes  forw’ard,  and  says  : 

‘ To-night  I will  give  a grand  dinner  in  the  Caffe  di  Europa.  You,  ; 
Signor  Director,  will  not  fail  to  honour  me.  There  will  be  lots  of 
dainty  dishes  never  before  tasted,  and  the  banquet-hall  will  be  a 
magnificent  sight  !’  If  he  is  then  interrupted,  and  told  that  he  is 
talking  nonsense,  and  that  he  is  an  unfortunate  patient  confined 
in  the  asylum,  he  remains  irresponsive,  and  cannot  adduce  any  argu- 
ment in  support  of  his  invitation,  which  he  then  abandons,  only  to 
present  it  again  soon  after  in  the  same  or  another  form. 


DEMENTIA  PARALYTICA 


799 


This  grandiose  delirium  is  very  variable.  From  day  to  day  the 
delirium  and  the  mental  disposition  change.  The  paratytic  who 
promises  one  million  to-day  wishes  to  give  twenty  to-morrow,  and 
the  day  after  asserts  that  he  has  nothing  at  all.  One  day  he  is  a 
prince,  then  a king  ; another  day  he  is  the  Pope  ; another,  God  ; 
then  he  becomes  silent  and  rather  uncertain.  On  another  occasion  he 
comes  forward  and  says  : ‘ I have  the  largest  diamond  in  the  world  ; 
it  is  bigger  than  my  fist,  and  in  the  night-time  it  illuminates  the 
room.  I have  it  in  my  desk  at  home.’  He  repeats  this  story  for  a 
week,  then  nothing  more  is  heard  of  it  ; wdien  reminded  of  it,  he 
maintains  an  attitude  of  indifference. 

Such  delirium  is  not  deeply  fixed,  and  cannot  be  maintained 
against  the  arguments  of  contradiction. 

In  manifest  contrast  with  the  bodily  condition,  which  is  always 
becoming  weaker,  the  feeling  of  strength  and  well-being  is  strangely 
exaggerated.  The  paralytic,  who  with  difficulty  can  stand  erect  on 
his  legs,  and  who,  owing  to  tremors  and  weakness,  is  unable  to 
perform  certain  delicate  movements,  speaks  of  his  great  strength 
and  boasts  of  his  ability  and  capacity,  maintaining  that  he  never  felt 
so  well  before,  that  he  can  run  many  miles  without  feeling  tired,  etc. 
Everything  reveals  the  most  classic  and  generalized  psychic  weak- 
ness. The  paralytic  loses  all  sense  of  reality,  and,  leading  a dreamy 
life,  forgets  what  he  said  but  a moment  before,  and  so  becomes 
incoherent  and  contradictory  in  all  his  statements.  He  does  not 
hesitate  to  utter  extreme  improbabilities,  and  can  bring  forward  no 
plausible  reasons  for  the  announcements  he  makes  ; he  lends  himself 
only  to  representations  of  stupid  and  absurd  dreams. 

Other  deliria  of  various  contents  alternate  episodically  with  the 
delirium  of  grandeur.  The  most  frequent  is  the  melancholic  delirium, 
accompanied  always  by  signs  of  progressive  dementia. 

Such  delirium  either  appears  very  suddenly  or  develops  slowly 
on  the  depressive  basis  of  mind,  and  sometimes  goes  on  to  the 
most  characteristic  manifestations  of  progressive  paralysis.  In 
other  instances  it  alternates  with  states  of  exaltation  (circular  form 
of  progressive  paralysis),  or  it  is  simply  an  episode  in  the  first  or 
second  stage  of  the  disease. 

The  patients  are  sad  and  bemoan  their  unhappiness,  thougli 
they  do  not  know  in  what  it  consists.  In  their  incertitude  they  are 
afraid  of  being  lost  and  ruined.  The  gloomy  prospect  of  the  future 
discourages  them  ; an  inner  restlessness  takes  possession  of  the  dis- 
ordered mind.  Whilst  at  the  commencement  of  the  disease  they 
were  conscious  of,  and  naturally  concerned  about,  the  mental  de- 
cadence which  they  observed  and  studied  with  anxiety,  now  the 
object  of  affliction  has  gradually  vanished  from  the  visual  point  of  con- 
sciousness. From  this  point  to  the  delirium  the  road  is  short.  They 
declare  themselves  sinners  undeserving  of  pardon,  accuse  themselves 
of  crime,  having  committed  enormous  thefts  and  merited  death  ; and 


8oo 


PSYCHIATRY 


so,  governed  by  these  delirious  ideas,  they  are  sometimes  goaded  oi 
to  suicide,  which  in  this  case  is  suggested  by  the  delirium,  just  a; 
at  the  beginning  of  the  disease  it  is  suggested  by  the  inability  o 
the  patient  to  prevent  his  progressive  decadence  (own  observations) 
When  these  melancholic  manifestations  occur  at  an  advanced  stage 
of  the  disease,  it  is  easy  to  judge  their  nature  by  the  accompanying 
features  of  dementia.  The  deliria  are  not  well  marked,  the  affec-[ 
tivity  weak,  the  associations  feeble,  so  that  the  patient  passed 
readily  from  one  idea  to  another,  often  in  complete  contrast  with  th(f 
preceding,  and  as  readily  abandons  these  delirious  ideas.  Sometimej|| 
in  the  course  of  melancholic  utterances  the  patient  launches  forth  aj' 
strange  idea  of  grandeur,  and  even  his  melancholic  manifestation'! 
themselves  may  partake  of  a grandiose  character.  j 

In  this  state  it  is  not  uncommon  for  paralytics  to  mutilate  them-| 
selves.  The  melancholia  not  infrequently  passes  into  stupor,  ir' 
which  case,  owing  to  the  absence  of  manifestations  of  speech,  it  is 
more  difficult  to  form  a judgment,  unless  we  are  aided  by  the 
somatic  phenomena,  the  preceding  history,  and  some  other  pheno- 
mena first  indicated  by  Baillarger,  such  as  the  relaxed  condition  o1 
the  features,  the  uncertainty  of  the  look,  the  passive  action  of  the 
muscles,  or,  vice  versa,  a katatonic  condition. 

The  hypochondriacal  delirium,  well  studied  by  Baillarger,  is 
frequent.  In  these  cases  the  patient  gives  utterance  to  the  strangestj 
and  oddest  sayings.  A woman  sees  a bone  lying  on  the  roadway 'j 
and  believes  that  it  belongs  to  her  own  body  ; other  patients  have 
no  eyes,  no  head,  no  legs,  or  do  not  feel  them  ; the  throat  is 
obstructed,  the  eyes  have  left  their  sockets,  someone  is  walking  in 
their  intestines,  or  devils  are  fighting  there  ; they  have  no  longer  any 
anus,  and  have  had  no  body  for  months  (delirium  of  negation) ; yeti 
they  eat  regularly,  and  pass  excreta.  In  some  cases  the  body  or  its 
individual  parts  seem  to  the  patient  much  reduced  in  bulk  (delirium 
of  smallness,  or  the  so-called  micro  maniacal  delirium  of  A.  Voisin). 
The  patients  believe  they  have  become  dwarfs  ; their  hands  are 
atrophied,  their  legs  so  small  and  short  as  to  be  unable  to  sustain 
the  weight  of  the  body.  The  opposite  delirium  is  suggested  by  ah: 
exalted  kinassthesis.  One  patient  in  the  Sales  Asylum  was  unwilling 
to  leave  his  dormitory  or  to  go  into  another  room,  because  his  body! 
was  enormous  ; he  was  excessively  large,  and  correspondingly! 
strong.  ‘ See,'  he  said  to  me,  ‘ the  great  height  Pve  reached.  Look  at' 
the  size  of  my  chest  and  the  beauty  of  my  form  P \ 

The  depressive  delirious  ideas  sometimes  assume  the  same' 
hyperbolic  character  (A.  Voisin’s  delirium  of  exaggeration).  It  is  al 
true  melancholic  megalomania  that  may  be  said  to  be  characteristic! 


of  dementia  paralytica.  One  patient  has  been  suffering  for  sixj 


thousand  years  ; another  has  three  hundred  worms  in  his  stomach 
another  complains  that  the}^  wish  to  open  his  belly  to  get  posses- j 
sion  of  the  precious  diamonds  contained  therein.  Similar  deliria | 


dementia  paralytica  8or 

are  met  with  only  in  senile  dementia,  and  these  much  more 
j rarely. 

\ The  delirium  of  pcvsccutioii  also  is  not  uncommon.  The  diagnosis 
is  easy.  In  paralytics  we  perceive  no  true  organization  or  systemati- 
zation of  the  delirium,  no  perplexity  in  the  delirious  affirmations  ; 

; there  is  less  coherence  between  the  ideative  content  of  persecution 
I and  the  conduct  of  the  patient,  less  logical  participation  of  the  affec- 
I tive  states  in  the  delirium,  no  gradual  substitution  of  the  delirious 
I for  the  normal  consciousness.  In  addition  to  this,  delirium  of  per- 
I secution  in  the  paralytic  may  be  episodic. 

I In  the  course  of  the  disease  an  acute  sensovy  dcliviuui  may  arise, 
preceded  by  a few  prodromata — headache,  restlessness,  increased 
I excitability,  intolerance  of  the  least  opposition  ; or  multiple  hallu- 
cinations, most  frequently  of  a terrifying  nature,  may  even  arise 
suddenly,  promptly  giving  origin  to  mental  confusion  and  intense 
agitation,  with  verbigeration,  impulsivity,  congested  face,  elevation 
of  temperature  of  one  or  two  degrees,  marked  tremors,  dry  and 
coated  tongue,  refusal  of  food,  constipation,  insomnia,  etc.  I am 
unable  to  state  definitely  whether  this  condition  is  due  to  cerebral 
congestion  or  a true  toxaemia  which  finds  favourable  conditions  for 
development  in  the  organism  of  the  paralytic.  In  any  case,  it  is 
always  one  of  the  gravest  accidents,  and  often  determines  death 
within  a short  time,  or,  in  less  serious  cases,  gives  rise  more 
rapidly  to  advanced  degrees  of  dementia. 

Besides  the  episodes  of  sensory  delirium,  we  frequently  have 
sensory  disturbances  varying  in  degree  and  content -illusions  most 
commonly  of  all,  then  the  so-called  psychic  hallucinations,  and  not 
rarely  true,  vivid  hallucinations.  Amongst  eighty-eight  paralytics, 
Geill  found  twenty-three  with  visual  and  auditory  hallucinations! 
apart  altogether  from  the  question  of  their  being  alcoholists  or  not! 

Whatever  be  the  form  assumed  by  the  malady,  provided  acute 
delirium,  pneumonia,  an  apoplectic  attack,  etc.,  does  not  cut  the 
patient  off,  the  most  complete  mental  decay  is  not  long  in  showing 
itself.  The  circle  of  ideas  becomes  invariably  narrower ; notions 
of  any  kind  whatsoever  become  faint,  uncertain,  and  confused  ; the 
smallest  defects  become  great  intellectual  losses.  Even  the  delirious 
iiideas  gradually  lose  their  colouring,  and  become  disconnected  ; the 
oatient  no  longer  has  any  desire  ; he  is  indifferent,  absurd,’  and 

>tupid,  and  is  no  longer  capable  of  the  simplest  forms  of  expres- 
>ion.  ^ 

No  longer  does  any  sentiment,  any  affection,  stir  the  mind  of 
i:he  paralytic.  In  their  places  we  find  some  irrational  outbursts 
'r  brief  phases  of  motor  agitation  of  the  most  incoherent  type, 
luring  which  he  is  often  noisy  and  sometimes  aggressive. 

Language,  when  not  reduced  by  articulatory  disturbances  to 
n unintelligible  muttering,  is  very  slow  in  its  manifestation,  and 
,ery  poor.  The  life  of  the  paralytic  in  the  last  stages  is  a particu- 

51 


802 


PSYCHIATRY 


larly  vegetative  one.  The  personality  is  destroyed,  and  the  con- 
sciousness is  now  melted  in  the  infinite  azure  of  the  universe.  He  , 
gives  expression  to  his  state  of  well-being,  even  when  he  is  incap-  ;• 
able  of  a single  thought  or  an  adequate  volitional  movement ; when,  | 
through  weakness,  or  paralysis,  or  contracture,  he  can  no  longer  : 
leave  his  bed  ; when,  owing  to  vesical  paralysis,  his  urine  has  to  i 
be  withdrawn  by  the  catheter ; when  deglutition  is  difficult ; when 
many  parts  of  the  body  are  covered  with  threatening  bedsores,  and 
cachexia  and  marasmus  are  hastening  him  on  to  another  world. 

Somatic  Phenomena. — Since  there  is  no  rule  as  regards  either 
the  time  or  the  site  of  invasion  of  the  morbid  process,  the  somatic 
symptoms  vary  accordingly,  and  are  combined  in  different  manners  ; 
with  one  another  and  with  the  psychic  disturbances,  obeying  no  j 
law  with  regard  to  the  timie  of  their  appearance  or  their  combina- 1 
tions. 

Tremor  is  one  of  the  most  important  of  the  somatic  phenomena, 
and  it  presents  special  features  in  the  site,  form,  and  number  of 
oscillations.  In  the  face,  the  first  muscles  to  be  attacked  are  par- 
ticularly the  zygomatic,  the  elevators  of  the  pinna,  nose,  and  upper 
lip,  the  orbicularis  oris,  and  the  muscles  of  the  tongue.  It  is  to  be  I 
noted,  however,  that  there  are  cases  in  which  the  hands  are  first  | 
affected.  This  tremmr  is  not  manifested  in  a state  of  repose,  but  i 
during  voluntary  movements,  and  especially  at  the  very  beginning  j 
of  a movement.  This  explains  why  it  is  that  the  tremors  of  the  I 
face  are  more  marked  when  the  paralytic  commences  to  speak,  _j 
and  the  tremor  of  the  tongue  when  he  attempts  to  protrude  or' 
retract  it.  Very  often  I have  noticed  tremor  of  the  lower  jaw  in^ 
the  act  of  opening  the  mouth.  In  these  cases  it  is  seen  that  the,! 
lowering  of  the  inferior  maxilla  is  not  uniform,  but  is  broken  into  | 
from  two  to  four  oscillations.  Sometimes,  as  I have  said,  the  tremor , 
appears  first  in  the  hands,  and  manifests  itself  in  the  writing.  ;j 

The  oscillations  are  rather  unequal.  On  the  whole,  they  appear^ 
to  be  choreic  movements  reduced  to  small  proportions.  Every;: 
muscle,  and  often  every  muscular  segment,  presents  separate  con-'j 
traction  ; therein  lies  the  chief  reason  of  the  great  inequality. 

It  is  particularly  in  the  most  delicate  and  complex  movements,'! 
such  as  writing,  that  the  tremor  is  apparent. 

As  in  almost  all  other  forms  of  tremor,  here  also  we  have  to  deal 
with  a loss  of  excito-motor  power  in  the  paths  and  various  muscles 
concerned  in  a given  movement.  Effort  increases  and  exaggerates 
the  tremor,  and  the  will  is  incapable  of  restraining  or  concealing  it. 

These  characteristics  show  that  the  motor  phenomena  and  the 
psychic  manifestations  are  marked  by  the  same  law,  which  is  summed 
up  in  the  incontinence,  the  diffusion  with  loss,  the  disproportion, 
the  want  of  rhythm,  and  the  ready  exhaustion  of  the  nervous, 
dynamism.  Inequality  of  the  oscillations  of  the  tremor  points  toi 


DEMENTIA  PARALYTICA 


803 


. inequality  and  incoherent  mobility  of  the  psychic  waves,  which 
. rise  unexpectedly  and  fall  with  great  rapidity.  In  some  cases  the 
ready  occurrence,  even  in  the  state  of  repose,  of  groups  of  contrac- 
tions represents  in  the  motor  field  what  in  the  psychic  sphere  is 
« represented  by  the  insurrection  of  ideas  and  emotions  without  associa- 
tive bonds,  so  characteristic  of  some  hereditary  forms  of  progressive 
- paralysis.  The  spreading  of  the  volitional  motor  impulse  over 

■ muscular  groups,  the  defect  of  fusion  and  direction  of  the  psycho- 
motor  currents,  which  in  some  paralytics  reveal  themselves  in  great 

: excitability  when  they  speak,  and  in  the  useless  participation  of  some 
of  the  facial  muscles,  correspond  exactly  to  the  ready  reawakening  of 
memal  representations  that  disappear  almost  as  soon  as  they  reach 

■ the  threshold  of  consciousness. 

'r  weakening  of  movement  in  the  paralytic  corresponds 

to  the  defect  m judgment  and  depth  of  thought.  The  convulsive 
mode  of  commencement  of  a volitional  movement  undoubtedly 
corresponds  to  the  vividness  of  insurrection  of  the  mental  represen- 
tations,  which  become  exhausted  in  their  sensory  element  The 
gait  of  the  paralytic  is  awkward,  tottering,  and  feeble,  except  in 
e , rst  stages  of  the  disease.  Even  in  those  cases  in  which  we 
get  delirium  of  grandeur  we  rarely  observe  that  self-assured  carriage, 
that  proud  bearing,  observed  in  megalomaniacal  paranoiacs.  There 
IS  no  energy  in  the  movements.  On  the  contrary,  there  is  often 
hesitancy,  uncertainty,  and  sometimes  inco-ordination.  His  step 
IS  slightly  longer,  less  rapid,  cumbersome,  and  heavy  ; he  requires 
a larger  base,  and  raises  his  feet  but  slightly  from  the  ground 

either  V assumes 

either  tabetic  or  paralytic  features. 

®“  difficulty  stand  erect  on  his 

feet  , he  stumbles  over  every  slight  obstacle,  and  it  becomes  neces- 
sary to  guard  him  against  dangerous  falls  by  keeping  him  in  bed 

Dowrrles"  7”^°^'!®’  ®al™>  or  restless,  as  vacuous  as  he  i^ 

L r K *7  contractures  are  often  set  up  in  the 

curled  muscles,  and  the  patient  lies 

lAtrnnb^^  majority  of  paralytics  grind  their  teeth. 

Atrophy  sets  in  in  some  of  the  muscles,  especially  the  interossei  • 

fibril  P*'®®®'"‘  exaggerated  mechanical  excitability  and 

^ brillar  movements.  Paramyoclonus  is  not  uncommon.  ^More 
rarely  we  observe  the  claw  hand. 

The  paralysis  may  overtake  the  muscles  of  deglutition  thus 

1™;“ '1  'S'.*"?' “ ‘i™  -"y 

Sment  of  the  h malady,  owing  to  early  involve- 

patfents  “ degenerative  process,  as  well  as  in  voracious 

Ld  sensibility  are  also  frequent,  especially  in  the 

fe  „eSr-i  v'"  ” ‘“'“f"  “<i «"».! 

P p ra  coefficients  necessary  for  normal  perception  are 

51—2 


PSYCHIATRY 


804 

in  reality  much  diminished.  Mere  noticing  of  objects  is  possible,  | 
but  not  differentiation  and  discrimination.  This  applies  particu-  j 
larly  to  taste  and  smell.  | 

Investigations  carried  out  in  my  clinique  b}^  the  oculist  Sgrosso  j 
showed  that  of  forty-seven  cases  of  progressive  paralysis  the  pupils  | 
were  unequal  in  thirteen  ; in  twenty-five  the  pupils  reacted  to  light  j 
and  in  accommodation  ; in  fifteen  slightly  or  not  at  all.  In  agree-  i 
ment  with  Moeli,  Utroff,  Siemerling,  I have  found  that  in  a certain  I 
number  of  paralytics  the  pupillary  reaction  to  light  is  retained, 
whilst  in  another  large  group  there  is  complete  pupillary  rigidity 
on  both  sides.  Sometimes  one  eye  does  not  react  directly  to  light, 
but  participates  in  the  consensual  reaction,  while  the  eye  that 
reacts  directly  shows  no  consensual  reaction  with  the  other  (Red- 
lich).  Irregularity  of  the  pupil  is  common.  Nystagmus  is  some- 
times observed  (Olliver)  ; paralysis  of  the  external  ocular  muscles 
occurs  very  rarely  (Bodicker).  In  a few  instances  I have  observed  | 
strabismus.  Diminution  of  the  visual  acuity  is  very  common  ; 
only  in  seven  out  of  forty-seven  paralytics  examined  by  Sgrosso 
was  it  found  to  be  normal.  The  colour  vision  is  also  altered,  and 
the  visual  capacity  for  the  form  of  objects  is  subnormal  (Olliver). 
The  visual  field  shows  concentric  restriction  sometimes  in  the  first  j 
stage  of  the  disease,  almost  always  in  the  confirmed  stage  (Sgrosso).  1 

Ophthalmoscopic  examination  reveals  the  presence  of  pupillary  | 
atrophy,  which  hardly  ever  attains  a degree  of  complete  atrophy,  ' 
as  in  tabes  dorsalis  (Sgrosso,  Olliver,  and  Wiglesworth).  | 

A varicose  condition  of  the  veins  of  the  optic  papillae  is  often  met  i 
with.  We  are  not,  however,  warranted  in  concluding  that  to  a given  1 
degree  of  general  paralysis  there  correspond  constant  ophthalmo-  _ 
scopic  lesions.  Further  on  we  shall  speak  of  the  histological  altera-  , 
tions  in  the  retina,  which  may  explain  all  these  functional  disturb- 
ances. 

A great  importance  has  rightly  been  attached  to  the  behaviour  . 
of  the  tendon-reflexes  in  their  relation  to  the  pathology  and  diag-  ; 
nosis  of  progressive  paralysis.  In  this  regard  the  observations  may  i 
be  classified  in  the  following  categories  : ' 

1.  Cases  in  which  the  patellar  reflex  remains  normal  up  to  an 

advanced  stage  of  dementia  paralytica.  'I 

2.  Cases  in  which  it  is  much  weakened  or  absent  from  the  begin- 
ning, and  sometimes  long  before  the  disease  reveals  itself  by  other 
symptoms. 

3.  Cases  in  which  the  tendon-reflex  is  much  exaggerated  (moie 
commonly  in  the  expansive  forms),  and  remains  so  throughout  the 
entire  course  of  the  disease,  or  else,  with  the  advance  of  the  disease, 
becomes  gradually  weaker  until  it  is  quite  extinguished. 

4.  Cases  in  which  the  patellar  reflex  is  normal  or  exaggerated  on 

one  side,  and  weak  or  absent  on  the  other.  | 

The  behaviour  of  the  patellar  reflex  often  coincides  with  tabetic  ; 


DEMENTIA  PARALYTICA 


805 

phenomena.  The  tabes  either  exists  prior  to,  proceeds  parallel  with, 
or  follows,  the  dementia  paralytica. 

The  abolition  of  the  patellar  reflex,  associated  with  loss  of  power, 
without  any  other  disorder,  is  frequent.  Psychic  depression,  with 
loss  of  memory  and  abolition  of  the  patellar  reflex  on  one  or  both 
sides,  constitutes  a characteristic  syndrome  of  dementia  paralytica. 
Other  observers,  amongst  them  Seppilli  and  Beatley,  have  arrived  at 
the  same  conclusions.  Amongst  sixty-five  cases  of  dementia  para- 
lytica, Beatley  found  the  knee-jerk  normal  in  eleven,  slightly  in- 
creased in  eight,  clearly  exaggerated  in  eighteen,  diminished  in  five, 
and  absent  in  eighteen  ; in  five  cases  it  behaved  differently  on  the 
two  sides. 

In  addition  to  the  symptoms  described,  there  are  others  which 
are  less  common,  and  which  we  may  rapidly  pass  in  review. 

Muscular  atrophy  in  progressive  paralysis  is  limited  to  the 
interossei  and  to  the  muscles  of  the  forearm.  Much  less  commonly  do 
we  find  the  muscles  of  the  trunk  and  lower  limbs  affected.  There  is 
no  true  reaction  of  degeneration,  but  only  a quantitative  alteration, 
associated  with  a greater  slowness  of  the  curve  of  the  electric  contrac- 
tion, or  it  may  be  an  alteration  in  the  contraction  provoked  bv 
percussion  of  the  muscles  (increased  mechanical  excitability  of  the 
muscles).  Lenzi,  in  the  course  of  methodical  clinical  investigations, 
has  observed  an  intermediate  form  of  reaction  of  degeneration,  con- 
sisting of  equality  in  reaction  on  kathodic  and  anodic  closing  and 
opening,  and  slowness  of  the  muscular  contraction  and  relaxation 
(Annali  di  Neurologia,  1899).  Judging  from  personal  observations, 

I would  say  that  the  atrophies,  infrequent  as  they  are,  coincide 
with  the  alcoholic  habits  of  the  patient. 

Bedsores  develop  with  great  readiness  in  some  paralytics 
wherever  pressure  is  exercised  on  the  skin  ; they  occur  most  fre- 
quently over  the  sacrum,  the  iliac  crest,  the  back,  the  knees,  the 
elbows,  etc.  They  are  for  the  most  part  superficial,  and  rarely  attain 
the  depth  and  severity  of  the  bedsores  that  occur  in  acute  myelitis 
and  cerebral  haemorrhage.  They  are  not  spontaneous,  being  always 
induced  by  pressure,  and  may  to  a certain  extent  be  prevented  by 
placing  the  patients  in  more  suitable  beds,  and  diligently  attending 
to  their  neatness  and  cleanness. 

Pneumonia  occurs  frequently,  and  in  an  insidious  manner.  It 
is  often  limited  to  a small  part  of  the  lung,  and  if  the  patient  appears 
no  worse  than  usual,  it  may  escape  observation ; but  it  is  recognised 
in  accurate  and  methodical  percussion  of  the  chest,  which  will  then 
reveal  a larger  or  smaller  area  of  dulness  or  a relatively  tympanitic 
. area  in  the  posterior  region  of  the  thorax,  and  often  over  the  base  of 
j lungs.  On  auscultation,  great  difficulties  are  experienced  in 
;;  judging  the  actual  state  of  the  lungs,  owing  to  the  indeterminate 
|i  character  of  the  vesicular  murmur  habitual  in  paralytics,  and  owing 
I to  the  loud  muscular  noises  in  the  patients.  Bronchial  breathing  is 


8o6 


PSYCHIATRY 


rare,  as  are  also  the  crepitant  rales  of  croupous  pneumonia.  More  ; 
frequently  we  find  rales  of  medium  coarseness,  scattered  or  grouped  ' 
together  with  a timbre  not  metallic.  Sometimes  a noise  closely  | 
resembling  that  produced  by  the  compression  of  a doughy  mass  in  | 
the  closed  hand  is  heard  ; it  is  almost  characteristic  of  this  form  of  i 
pneumonia.  Cough  and  dyspnoea  are  often  absent  ; sometimes  ! 
there  is  expectoration. 

This  form  of  pneumonia  may  be  produced  experimentally  by 
section  of  the  vagus  (Frey,  Traube,  Bianchi),  and  undoubtedly  co- 
incides with  the  degeneration  of  the  pneumogastric  nerves  demon- 
strated b}^  myself.  Many  factors  play  a part  in  its  genesis  and 
development,  but  in  every  case  it  is  produced  by  the  same  micro- 
organism as  occurs  in  croupous  pneumonia  (Fraenkel’s  diplococcus),  , 
which  would  not  exert  its  pathogenic  action  except  after  section  or  | 
degeneration  of  the  vagus — that  is  to  say,  when  the  soil  has  been 
made  favourable  either  by  an  altered  chemistry  or  a weakening  of  | 
the  mechanism  of  defence,  in  consequence  of  diminished  or  sup-  ' 
pressed  action  of  the  vagus  and  its  centres.  This,  after  a consider-  | 
able  number  of  observations  and  experiments,  was  demonstrated  by  j 
myself  (Bianchi,  ‘ La  fulmonite  dei  paralitici,’’  La  Psichiatria,  etc.,  ! 
i8g6),  and  subsequently  by  Piccinino,  who  carried  out  investigations  j 
in  my  clinique.  | 

Furuncles  are  not  uncommon  ; in  one  case  I had  to  incise  as  many  -j 
as  eighteen.  Sometimes  multiple  and  even  symmetrical  lipomata  ' 
have  been  observed  (Targowla).  I 

The  thermogenesis  is  anomalous.  Methodical  observations 
carried  out  on  a considerable  number  of  paralytics  show  a great 
difference  in  behaviour  of  the  temperature  in  different  cases — a fact  ^ 
that  cannot  yet  be  satisfactorily  explained.  ! 

There  are  cases  in  which  the  axillary  temperature  remains  I 
normal  in  others,  hyperpyrexia  or  hypopyrexia  prevails  ; or  the 
temperature  remains  normal  or  subnormal  for  some  hours  or  several 
da}^s,  then  rises  at  other  hours  or  on  other  days  without  any  apparent  j 
reason.  Pneumonia,  bedsores,  meningo-encephalitis,  intestinal  I 
auto-intoxications,  and  those  toxsemias  due  to  functional  insufti-  j 
ciency  of  the  liver,  kidneys,  and  suprarenal  capsules,  are  amongst  ,j 
the  causes  that  have  been  offered  in  explanation  of  these  irregular 
elevations. 

The  alterations  of  the  tissue  metabolism  which  have  claimed 
the  attention  of  clinicians  bear  some  relation  to  the  changes  of 
temperature.  Among  the  findings  are  diminution  of  the  chlorides 
(Leubuscher),  increase  of  the  phosphates  (Marro),  diminution  of  the 
specific  gravity  of  the  blood  and  of  the  haemoglobin  (^Mrster), 
peptonuria  (Marro,  Fronda),  and  also  a volatile  phosphorous  com- 
pound, basic  and  resembling  aconitine  (Selmi).  Acetonuria  is  not  | 
uncommon  (Rivano).  According  to  Lailler,  the  elimination  of  the  ^ 
products  of  regressive  metamorphosis  would  be  diminished  in  the 


DEMENTIA  PARALYTICA 


807 


depressed  state,  and  increased  in  the  state  of  sorrowful  agitation. 
Phosphoric  acid  does  not  appear  to  be  increased  in  the  urine. 
Diabetes  is  very  rare,  but  not  albuminuria.  Vassale  and  Chiossi 
found  hyaline  and  granular  tube-casts  in  nine  cases  of  progressive 
paralysis,  and  they  attribute  this  to  the  alteration  in  the  constitution 
of  the  blood  produced  by  toxic  agents.  Polyuria  is  rather  frequent 
(Falret,  Turner). 

Galante  has  often  found  hyperpepsia  coinciding  with  the  phases 
of  exaltation  and  well-being,  and  hypopepsia  with  the  phenomena 
of  depression. 

The  congestive  attacks,  which  in  some  cases  are  first  to  appear  upon 
the  scene,  occur  episodically  in  the  confirmed  malady.  They  vary 
in  degree. 

1.  If  there  is  a simple  congestive  flux  to  the  head,  the  face  is 
injected,  the  veins  of  the  forehead  and  the  neck  are  more  evident 
and  turgid,  the  excitability  is  more  marked,  the  consciousness  more 
confused,  the  speech  slower  and  more  uncertain,  and  the  temperature 
elevated  by  a few  decimals. 

2.  To  these  somatic  and  psychic  symptoms  there  is  added  in  some 
cases  a lively  motor  agitation,  with  shouting  and  more  or  less 
violent  delirium,  lasting  from  several  hours  to  two  or  three  days  ; 
it  disappears  gradually,  leaving  behind  marked  mental  confusion, 
which  in  its  turn  diminishes,  but  does  not  entirely  disappear. 

3.  In  other  cases  we  have,  as  in  the  apoplectiform  attacks,  loss 
of  consciousness,  gradual  or  sudden,  down  to  profound  coma.  In 
this  state  the  face  is  injected,  the  veins  are  turgid,  the  temporal 
arteries  pulsate  strongly  ; the  pupils  are  rigid  and  often  myotic  ; 
the  temperature  in  the  axilla  sometimes  rises  to  40°  C. ; the  skin  is 
dry  or  covered  with  sweat  ; the  pulse  is  full,  and  more  or  less  rapid, 
muscular  spasms  are  often  observed  in  the  face  or  neck  and  in  the 
limbs  ; there  is  almost  always  conjugate  deviation  of  the  head  and 
eyes  ; one  or  other  side  of  the  body  is  seen  to  be  paralyzed  ; there 
is  involuntary  loss  of  urine  and  of  faeces.  Such  a condition  always 
disappears  gradually  in  a few  hours  or  days,  leaving  behind  it  mental 
confusion  and  hemiparesis  or  hemiplegia,  which  in  most  instances 
also  disappears.  These  attacks  are  sometimes  preceded  by  marked 
salivation — the  result,  perhaps,  of  stimulation  of  the  cortical  centre 
of  the  salivary  glands  (Fere). 

The  paralytic  and  aphasic  attacks  reveal  themselves  in  paralysis 
localized  in  one  side  or  in  one  limb  only,  or  else  in  a general  motor 
collapse,  sometimes  terminating  fatally,  and  accompanied  neither 
by  marked  congestive  phenomena  nor  by  convulsions  or  coma. 
In  most  cases  the  paresis  or  paralysis  is  transitory.  In  some  cases 
\ the  paralysis  affects  exclusively  the  function  of  language.  It  is  in 
; this  way  that  those  complex  aphasic  forms  of  which  Ascher  speaks, 

■ and  which  are  often  aphasic-dysarthritic,  announce  themselves  and 
dominate  the  symptomatic  picture.  They  are  not  accompanied  by 


e 

808  PSYCHIATRY 

evident  signs  of  cerebral  congestion.  Sometimes  they  are  due  to 
lymphatic  stasis,  and  in  these  cases  we  get  an  elevation  instead 
of  a lowering  of  the  temperature. 

The  epileptiform  attacks  may,  like  the  apoplectiform,  precede 
the  commencement  of  the  disease  for  some  time,  and  may  even  be 
frequently  repeated  at  longer  or  shorter  intervals  in  the  course  of 
the  malady. 

In  the  confirmed  stage  the  Jacksonian  and  vertiginous  forms  are  j 
more  frequent,  especially  the  former,  and  also  that  form  called  i 
eclampsic  by  some  authors  (Cullerre),  which,  however,  does  not 
merit  a separate  description.  The  epileptiform  attack  is  generally  of 
a tumultuous  nature.  Without  any  warning,  or  with  some  fleeting 
phenomena  which  escapes  observation,  the  paralytic  is  seized  with  i 
cramps,  at  first  limited  to  one  limb,  but  soon  extending  to  other  1 
muscular  fields.  The  consciousness  is  clouded.  The  patient  | 
mutters  words  quite  unintelligible.  Soon  there  are  superadded  j 
conjugate  deviation  of  the  head  and  eyes,  foaming  at  the  mouth,  | 
congested  face,  dilated  pupils,  and  profuse  sweats.  The  tempera- 
ture rises  to  38-5°  to  39°  C.  In  rare  instances,  when  the  attack  is 
very  grave,  so  that  coma  supervenes  and  there  is  danger  of  collapse, 
it  rises  to  40°  C.  or  more. 

The  duration  of  the  attack  varies  from  half  an  hour  to  many 
hours,  or  even  several  days.  In  the  latter  case,  however,  it  soon  loses  _ 
its  initial  intensity.  The  consciousness  becomes  partly  restored, 
so  much  so  that  the  patient,  when  addressed  in  a loud  voice,  opens  i 
his  eyes,  or  gives  some  sign  that  the  stimulus  has  arrived  at  the  j 
threshold  of  perception.  The  temperature  descends  to  some  extent,  ! 
but  always  remains  above  the  normal.  The  cramps  become  limited 
to  some  groups  of  muscles.  The  conjugate  deviation  of  the  head  1 
and  eyes  often  persists  much  longer.  j 

The  convulsion  may  remain  circumscribed  or  it  may  change  its  | 
seat.  Intermissions  and  remissions  may  occur,  and  later  on  the  , 
attack  may  assume  its  former  intensity.  If  it  is  prolonged  and  : 
widespread,  signs  of  collapse,  a more  marked  elevation  of  the  tern-  | 
perature,  and  a fatal  issue  may  occur.  j 

The  apoplectiform  and  epileptiform  accessions  are  less  common  \ 
in  women. 

With  regard  to  the  cause  of  these  attacks,  the  very  large  number  ! 
of  autopsies  on  paralytics  performed  in  the  Naples  Asylum,  together 
with  accurate  clinical  examination  of  many  of  them,  do  not  favour  | 
the  hypothesis  either  of  a marked  congestive  flux  or  of  an  intense 
inflammatory  process  in  any  region  of  the  brain.  At  the  autopsy  l 
we  may  find  an  intense  congestion,  although  there  were  no  apoplec- 
tiform attacks  during  life.  In  other  cases  in  which  death  was  due  j 
to  epileptiform  attacks  not  only  was  there  no  sign  of  inflammatory  1 
adhesion  of  the  pia  mater  to  the  cortex,  the  pia  being  detached  j 
with  the  greatest  facility,  but  I could  not  find  even  any  indication  j 


DEMENTIA  PARALYTICA  809 

of  congestion  either  in  the  cortex  or  in  the  white  substance.  Ad- 
I hesion  of  the  cortex  to  the  pia  mater  in  the  Rolandic  region  occurs 
I less  frequently  than  Tamburini  and  Riva  would  make  out.  On 
I the  other  hand,  I have  often  found  lymphatic  stasis  even  to  the 
extent  of  cystic  formations  of  the  size  of  a hazel-nut  in  the  frontal 
and  Rolandic  lymphatic  channels,  and  I am  led  to  regard  this  ana- 
: tomical  condition  and  the  local  poisoning  arising  from  it  as  perhaps 
the  most  frequent  causes  of  the  said  attacks.  Furthermore,  in  a 
certain  number  of  cases  the  attacks  are  decidedly  uraemic.  Capriati, 
who  investigated  this  subject,  found  marked  albuminuria,  hyaline 
tube-casts,  haematuria,  and  scantiness  of  urine  in  a paralytic  who 
was  struck  down  by  a severe  epileptiform  attack  that  terminated 
fatally  in  twenty-four  hours. 

According  to  Bechterew,  the  pressure  on  the  lymphatic  vessels 
: does  not  reveal  itself  by  any  symptom,  so  long  as  it  is  not  equal  to 
that  in  the  carotid  artery.  When,  however,  modifications  of  the 
carotid  pressure  occur  from  any  cause  whatsoever,  epileptiform 
accessions  would  take  place  owing  to  the  local  compression.  I am 
of  opinion  that  too  great  importance  is  attached  to  this  compression, 
and  too  little  to  the  hindered  flow  in  the  lymphatic  vessels,  which 
must  induce  very  considerable  disturbances  of  the  nutritive  inter- 
: change  in  the  nerve-cells. 

The  hy steroid  attacks,  which  are  said  to  occur  especially  in 
women,  owing  to  the  known  association  of  hysteria  with  organic 
diseases  of  the  nervous  system  (A.  Voisin),  and  the  tetanoid,  or,  as 
: Magnan  calls  them,  spinal  attacks,  the  genesis  of  which  is  to  be 
; referred  to  the  variable  localization  of  the  morbid  process  in  the 
; spinal  medulla,  are  very  rare. 

According  to  Seppilli  and  Riva,  there  exists  a senile  form  of 
I;  progressive  paralysis  having  different  anatomical  features  from 
I the  common  form.  These  consist  in  true  or  dissecting  aneurisms 
mf  the  cerebral  arteries,  hyperplasia  of  the  interstitial  connective 
tissue,  and  diffuse  atheroma.  Its  clinical  features  would  be  the 
atheiomatous  pulse,  the  rarity  of  the  apoplectiform  accessions,  the 
lesser  tendency  to  hyperpyrexia,  and  the  absence  of  ambitious  and 
expansive  delirium. 

Progressive  paralysis  in  old  persons  is  either  true  paralysis 
differing  only  in  presenting  characteristics  of  senility,  or  it  is  a 
dementia  resulting  from  multiple  foci  of  softening,  with  phenomena 
of  aphasia  and  especially  of  aphemia. 

Progressive  paralysis  in  women  presents  no  great  difference. 
The  details  of  the  somatic  phenomena,  the  course  of  the  affection 
(Buccola),  and  the  psychic  manifestations,  must  be  referred  to  the 
mental  constitution  of  woman,  in  whom  the  mental  decadence  is 
more  profound  and  more  prompt,  the  delirium  of  grandeur  less 
common  and  less  paradoxical,  whilst  eroticism  is  more  evident  in 
the  delirious  manifestations. 


8 10 


PSYCHIATRY 


Numerous  observations  have  clearly  shown  me  that  no  difference 
exists,  in  any  stage  of  the  disease,  either  in  symptomatology  or  in 
course,  between  progressive  paralysis  arising  from  syphilis  and  that  : 
from  any  other  cause.  : 

From  a clinical  point  of  view,  progressive  paralysis  is  one  single  | 
affection.  There  is  nothing  to  warrant  us  admitting  a dual  nature.  | 

Pathological  Anatomy. — We  have  to  deal  with  a degenerative 
process  (according  to  others  an  inflammatory  process),  which  at 
first  is  localized,  but  gradually  invades  the  entire  nervous  system. 
The  organs  of  the  highest  structure  are  profoundly  altered  by  the 
progressive  substitution  of  the  specific  elements  by  connective  i 
tissue.  I 

In  the  cranial  bones  there  are  noted  marked  congestion  of  the  ! 
diploe,  hyperostosis,  disappearance  of  the  diploe,  and  hardening. 
The  weight  of  the  skull-cap  is  increased  (Fraenkel).  The  dura  mater 
is  thickened,  turbid,  adherent  here  and  there  to  the  cranium,  and  | 
encrusted  with  calcareous  plaques,  especially  in  the  region  of  the 
falx.  On  the  internal  aspect  false  membranes  are  found,  sometimes 
very  thick,  at  other  times  very  thin,  more  or  less  vascular,  forming  | 
one  or  more  pouches  and  sometimes  a true  haematoma  of  the  dura  | 
mater  (hypertrophic  and  haemorrhagic  pachymeningitis).  In  some  ■! 
cases  we  find  in  the  subdural  space  a collection  of  blood,  in  others  a i 
certain  quantity  of  serum.  As  a rule,  the  arachnoid  is  thickened,  j 
and  is  always  more  or  less  turbid.  The  opacity  is  most  marked  | 
along  the  course  of  the  sulci  and  median  veins.  Sometimes  small  i 
pearly  granulations  are  scattered  over  the  external  aspect,  or  here  ’ 
and  there  fibrinous  products  are  found.  It  is  always  infiltrated 
with  serum.  The  spinal  portion  of  this  membrane  sometimes  has 
scattered  over  it  new  formations  of  i to  5 millimetres  in  diameter, 
composed  of  cellular  tissue  infiltrated  with  calcareous  salts  (Voisin),  : 
or  true  bony  productions  (Tamburini).  The  lesions  of  the  pia 
mater  are  analogous  to  those  of  the  arachnoid.  Here  also  we  < 
find  thickening,  opacity,  hyperaemia  or  anaemia,  fibrous  layers  or  •! 
bony  plaques,  sometimes  pus,  in  other  instances  haemorrhage. 

The  meshes  of  the  pia  are  dilated  by  an  infiltration  of  fluid 
forming  a kind  of  gelatinous  cap  on  the  convex  surface  of  the  brain, 
most  marked  in  the  anterior  regions.  It  is  sometimes  adherent 
to  the  brain,  especially  over  the  frontal  lobes  and  Broca’s  convolu- 
tion (Tamburini,  Riva,  and  Stenger),  so  that  on  attempting  to  detach 
it  the  underlying  gray  substance  suffers  laceration  at  the  summit 
of  the  convolutions. 

The  cerebrum  is  found  to  be  congested  and  marbled  with  vessels, 
sometimes  ulcerated  in  certain  convolutions  (these  are  the  parts  where  | 
the  cortex  has  remained  attached  to  the  pia  mater),  oedematous,  pale,  j 
small,  and  hard.  This  depends  on  the  period  at  which  death  occurs,  1 
and  on  the  immediate  cause  of  death.  The  convolutions  are  smaller  ! 


DEMENTIA  PARALYTICA 


8ii 


(Stenger  and  others),  the  sulci  wider,  the  gray  substance  thinner,  the 
white  substance  generally  harder.  The  ventricular  ependyma  is 
thickened  and  scattered  over  with  granulations  ; the  ventricles  are 
dilated  and  filled  with  fluid.  On  section,  the  white  substance  in 
some  cases  has  presented  notable  dilatation  of  the  perivascular 
spaces,  producing  an  appearance  resembling  Gruyere  cheese  (Lock- 
hart-Clarke,  Golgi,  Vassale).  In  other  cases  we  find  small  destruc- 
tive foci,  especially  softening,  in  the  capsule  (Zacher)  or  in  the  nuclei 
of  the  base  or  subcortical  foci  (personal  observations).  The  vessels 
are  seen  to  be  distended  and  full  of  blood  ; they  often  become  hard 
or  deformed,  and  here  and  there  are  dilated  and  sclerosed,  showing 
various  kinds  of  degeneration — colloid,  hyaline,  waxy,  fatty,  athero- 
matous (Greiff,  Dagonet,  Mendel) — or  incrustations  of  lime-salts 
in  the  vessel-walls,  which  sometimes  are  scattered  over  with 
aneurisms. 

With  the  nuclear  proliferation,  more  marked  in  certain  points, 
there  also  coincides  an  abundant  migration  of  white  blood-corpuscles 
under  the  adventitia,  which  is  also  overloaded  with  nuclei  of  new  for- 
mation. This  gives  rise  to  dilatation  of  the  perivascular  spaces,  which 
on  the  one  hand  offers  an  impediment  to  the  course  of  the  lymph, 
and  on  the  other  leads  to  the  formation  of  true  cysts  filled  with 
lymphatic  fluid,  and  exerting  compression  on  some  part  of  the 
cerebral  surface.  The  hypothesis  of  the  new  formation  of  vessels 
in  the  cortical  substance  seems  admissible  (Lubimow,  A.  Voisin, 
Mirzejewski,  Robertson). 

The  hyperplasia  of  the  interstitial  tissue  generally  commences, 
according  to  Meynert,  in  the  deepest  layer  of  the  gray  substance, 
thence  spreading  to  the  others.  Nuclei  and  spider  cells  are  found 
in  great  abundance  : their  number  is  in  many  cases  enormously 
increased.  It  is  in  the  frontal  lobes  that  Mendel  has  found  the  spider 
cells  to  be  most  numerous,  and  also  increased  to  three  or  four  times 
their  normal  size.  Bundles  of  connective  tissue  are  seen  on  the 
thickened  ventricular  ependyma,  while  on  the  epithelial  surface  of 
the  ventricles  there  are  formed  true  granulations  of  variable  size, 
to  which  has  been  given  the  name  of  papilliform  fibromata,  and  the 
connective-tissue  nature  of  which  has  been  recognised  by  Magnan 
and  Mirzejewski. 

It  is  difficult  to  say  whether  the  nuclear  and  leucocytic  bodies 
described  by  authorities  in  the  past  correspond  to  the  plasma- 
cells  described  more  recently  by  Unna,  Marschalko,  and  Vogt. 
These  plasma-cells  [plasmazellen)  have  altogether  peculiar  morpho- 
logical characteristics — eccentric  position  of  the  nucleus,  peripheral 
distribution  of  the  protoplasm,  and  a clear  zone  in  the  centre  of  the 
cell-body.  They  are  found,  not  only  in  general  paralysis,  but  also 
in  uiany  processes  of  new  formation  (tuberculosis,  lupus,  leprosy, 
soft  chancre,  fungoid  mycosis,  etc.).  A difference  of  opinion  prevails 
as  to  the  origin  of  these  cells.  Unna  holds  them  to  be  derived  from 


8i2 


PSYCHIATRY 


the  fixed  cells  of  the  connective  tissue,  whilst  Marschalko  regard 
them  as  former  leucocytes,  or,  in  other  words,  migrated  and  trans 
formed  lymphocytes.  In  the  brain  they  are  found  in  abundance  ii 
the  adventitial  spaces.  Vogt  distinguishes  them  clearly  from  th< 
nuclei  (lymphocytes),  and  regards  the  presence  of  these  cells  a: 
pathognomonic  of  dementia  paralytica.  They  are  found  in  very  larg(j 
numbers  around  the  bloodvessels,  especially  in  the  lymphatic  ane 
adventitial  spaces,  whence  they  may  sometimes  migrate  (Vogt) 
It  is  to  be  noted  that  Mahaim  disputes  the  pathognomonic  valu(, 
attributed  to  the  plasma-cells  in  progressive  paralysis,  and  assignij 
the  highest  significance  to  the  vascular  lesions  and  to  the  lymphath 
infiltration  (Bull,  de  C Academic  R.  de  Belgique,  igoi). 

They  are  much  more  plentiful  in  the  anterior  part  of  the  brair 
than  in  the  occipital  region.  This  seems  to  depend  on  the  differeni 
structure  of  the  convolutions  (not  excluding  the  supposition  that  ii 
depends  rather  on  the  different  functional  dignity  of  the  cortica] 
provinces)  and  also  on  the  period  of  development  of  the  paralytic 
process,  the  plasma-cells  being  more  numerous  where  the  process  is 
acute  and  recent. 

This  view  supports  the  theory  of  the  inflammatory  nature  ol 
dementia  paralytica.  | 

In  addition  to  plasma-cells,  numerous  mastzellen  are  found.  | 

The  nerve-elements  undergo  a series  of  alterations.  At  first  the 
contour  of  the  cell  is  more  irregular  and  less  clearly  defined  (Awtow-' 
kratow)  ; the  protoplasm  becomes  swollen,  oedematous,  and  turbid,' 
and  afterwards  undergoes  atrophy  and  degeneration,  varying  in 
degree  and  kind — fatty,  pigmentary,  fatty-granular,  hyaline  (Lieb-!j 
mann,  Dagonet).  The  nuclei  are  at  first  displaced,  and  are  no  longer  | 
round,  as  in  the  healthy  cell,  but  irregular,  enlarged  (Mendel,  But- 
zelsk}^),  and  lose  their  contour  ; the  nucleoli  also  disappear,  and  ati 
the  same  time  the  protoplasm  is  seen  to  be  atrophied  and  to  contain 
vacuoles.  The  pericellular  lymphatic  spaces  are  enlarged  owing  tO; 
the  diminution  of  the  protoplasmic  mass,  and  in  the  majority  of  cases^' 
lymphatic  corpuscles  collect  there.  Here  and  there  we  come  across 
sclerosis  of  the  cells.  ^1 

The  accompanying  illustration  shows  a group  of  cortical 
cells  which  present  various  stages  of  the  degenerative  process, 
consisting  in  the  partial  disappearance  of  the  neurofibrillar  network 
(R.  y Cajal’s  method  of  staining). 

Sometimes  very  little  is  left  of  the  cell-protoplasm  ; it  is  broken 
in  pieces,  in  some  cases  reduced  to  detritus,  whilst  in  others  it  is 
diminished,  vacuolated,  and  deformed  without  being  broken.  In  the 
first  case  the  nucleus  is  preserved,  and  survives  the  disappearance  of 
the  protoplasm  ; in  the  second  case  it  is  altered,  and  not  readily  dis-  j 
tinguished  from  the  protoplasm  (Grimaldi,  A diNeurologia,  1897).  j 
The  nerve-prolongations  also  present  alterations,  swellings,  varicosity,  | 
hypertrophy  of  tlie  axis-cylinder,  fatty-granular  degeneration  of  the 


DEMENTIA  PARAEYTICA 


3i3 

medullary  sheath  of  the  myelinated  fibres,  sclerosis  of  the  axis- 
cylinder  (Pick),  and  entire  disappearance  of  the  nerve-prolongation, 
so  that  in  a short  time  the  cells  lose  their  relations  with  the  periphery 
or  with  the  other  cells.  Tuczeck  found  a marked  diminution  in  the 
number  of  medullated  nerve-fibres  in  certain  parts  of  the  brain, 
especially  the  tangential  fibres  of  the  granular  layer.  This  was  con- 
firmed by  the  investigations  of  Greppin,  Kronthal,  and  Zacher. 
The  disappearance  of  medullated  fibres  may  take  place  in  deter- 
mined sites,  or  follow  the  direction  of  certain  commissural  paths 


Fig.  99. — From  the  Anterior  Rolandic  Convolution  (Cajal’s  JMethod  ; 
Magnified  500  Diameters). 

The  fibrillar  apparatus  is  variously  altered  in  the  different  cell-elements  : in  some  it 
is  more  or  less  diminished,  in  others  it  has  disappeared  entirely. 

(Tuczeck,  Meschede).  Amyloid  or  colloid  bodies  are  found  in  the 
localities  where  the  number  of  nerve-fibres  is  most  reduced. 

Tremors,  some  forms  of  defective  articulation,  abolition  of  the 
tendon-reflex  in  some  cases,  and  pneumonia,  may  be  attributed  to 
lesions  of  the  peripheral  nerves  (Bianchi). 

Lissauer  has  found  lesions  in  the  optic  thalamus.  An  important 
feature  is  that  the  thalamic  lesions  would  appear  to  be  related  in 
some  way  with  the  paralytic  attacks,  for  of  nine  cases  in  which  these 
attacks  had  occurred,  several  presented  lesions  in  the  thalamus. 
The  same  degenerative  lesions  were  studied  by  Zagari  in  cases  in 
iMendel’s  clinique,  and  in  these  also  paralytic  attacks  had  taken  place. 


8i4 


PSYCHIATRY 


Hoche  found  degeneration  of  the  anterior  and  posterior  roots 
entirely  independent  of  the  usual  degenerative  lesions  of  the  posterior 
columns  and  anterior  cornua. 

Atrophy  of  the  nerve-fibres  of  the  cerebellum  is  frequent. 

Schutz  found  marked  lesions  in  the  nuclei  of  the  hypoglossal  and 
facial  nerves,  whilst  he  could  demonstrate  no  change  in  the  nuclei 
of  the  oculo-motor  nerve.  In  paralytics  in  whom  there  had  existed 
rigidity  of  the  pupils,  he  found,  in  the  region  of  the  third  ventricle 
and  at  the  superior  extremity  of  the  aqueduct  of  Sylvius,  a marked 
diminution  of  the  nerve-fibres  ; in  those  cases,  on  the  contrary, 
where  there  had  been  no  pupillary  rigidity  these  fibres  were! 
normal. 

The  histological  alterations  found  in  the  spinal  cord  of  paralytics 
are  no  less  important  than  those  found  in  the  brain.  Some  of  thei 
lesions  are  systematized,  others  are  diffuse.  The  most  frequent  is 
degeneration  of  the  column  of  Burdach,  or  of  a part  of  it,  such  as  the 
zone  of  entrance  of  the  posterior  root  (Westphal,  Fornario,  Sanna 
Safaris,  etc.),  especially  in  those  cases  in  which  there  had  existed 
evident  signs  of  tabes — e.g.,  abolition  of  the  patellar  reflex.  The 
degeneration  of  the  pyramidal  bundle  may  be  primary,  or  it  may  be 
a descending  degeneration  resulting  from  a profound  destructive 
process  in  the  cortical  motor  zone.  Sometimes  the  degeneration  is' 
diffuse  or  in  irregular  islands,  following  no  system  of  bundles. 
Degeneration  of  the  column  of  Goll  is  very  rare.  The  cells  of  the 
spinal  medulla  are  less  altered  than  those  of  the  brain,  but  there, 
too,  we  find  the  same  histological  changes.  Again,  a central  lesion! 
of  the  spinal  cord  is  common.  The  central  canal  is  filled  with  nuclei,! 
and  there  is  also  a considerable  increase  of  these  for  some  distance  in 
the  surrounding  zones.  Here  and  there  the  central  canal  is  dilated, 
as  though  by  necrotic  destruction  of  a particular  mass  of  nuclei  or 
by  peri-ependymar  excavation,  giving  rise  to  an  appearance  closely, 
resembling  syringomyelia.  These  dilatations  of  the  central  canall 
are  irregular  (D’  Abundo).  '[ 

The  posterior  roots,  the  sympathetic  ganglia  (Bennet  and!* 
Poincare),  the  ganglia  of  the  posterior  roots  (Piccolomini,  Orr,  and ’I 
Rows),  and  the  peripheral  nerves — not  only  the  cutaneous  branches 
of  these  in  the  neighbourhood  of  bedsores  (Dejerine),  but  the  whole 
nerves^ — are  attacked  by  the  degenerative  process.  This  degenera- 
tion is  parench\/matous,  and  is  independent  of  the  state  of  the 
respective  cells  of  origin,  both  in  the  spinal  cord  and  in  the  bulb. 

The  degenerative  process  in  progressive  paralysis  is  not  limited 
entirely  to  the  nervous  system.  In  advanced  stages  of  the  disease 
all  the  other  organs  are  more  or  less  involved  in  the  same  process, 
and  present  profound  alterations.  The  heart  is  diminished  in  i 
weight,  pale,  soft,  and  fatty.  Hypertrophic  dilatation  of  the  heart,  j 
atheroma,  and  ulceration  of  the  aorta  are  not  uncommon.  The  ' 
lungs  almost  always  show  hypostasis,  congestion,  oedema,  purulent  j 


DEMENTIA  PARALYTICA 


815 


I bronchitis,  gangrene,  old  or  recent  tubercular  nodules,  emphysema 
I induration,  recent  pleurisy  or  old-standing  pleuritic  adhesions’ 
^ hydrothorax,  etc.  The  most  frequent  of  these  lesions  is  pneu- 
^ monia,  which  has,  as  already  noted,  clinical  characteristics  of  its 
f own,  and  presents  anatomo-pathological  features,  which,  if  not 
( characteristic  of  progressive  paralysis,  yet  occurs  so  frequ’ently  in 
that  disease  as  to  justify  the  term  of  pneumonia  of  paralytics. 

Amongst  the  diseases  of  the  abdominal  viscera,  marked  dilata- 
tion of  the  stomach  is  common.  It  follows  upon  chronic  intestinal 
catarrh,  sometimes  with  slate-coloration  of  the  mucous  mem- 
brane. 

The  liver  is  congested,  or  very  pale,  or  of  nutmeg  appearance. 
Somehmes  there  is  slight  cirrhosis,  at  other  times  perihepatitis 
adhesions,  and  thickening  of  the  capsule.  Degeneration  of  the 
hepatic  cells  with  increase  of  the  connective  tissue  is  common 
(Robertson).  Unpublished  researches  carried  out  in  my  clinique 
strongly  confirm  these  facts. 

The  spleen  is  small,  hard,  sometimes  soft,  or  there  is  perisplenetic 
thickening  of  the  capsule,  which  often  contains  fibroid  plaques. 

Renal  lesions  are  very  common,  and  there  is  no  doubt  that  they 
must  play  an  important  part  in  the  symptomatology  of  progressive 
paralysis.  Mickle  found  the  granular  kidney  in  18  per  cent,  of  his 
paralytics.  The  percentage  in  the  Naples  clinique  is  much  higher 
and,  further,  there  have  been  noted  adherent  capsule,  cystic  forma- 
tions, acute  or  subacute  parenchymatous  nephritis  (the  latter  in  14 
per  cent.),  congestion,  amemia,  suppuration,  and  sometimes  pyelitis. 

Acute  or  chronic  cystitis  is  also  frequently  found,  with  simple 
hypertrophy  of  the  prostate  and  hypertrophy  of  the  bladder  walls 
which  may  attain  a thickness  exceeding  2 centimetres,  leading  to 
almost  complete  disappearance  of  the  cavity  (D’  \bundo) 

According  to  Mendel  and  others,  progressive  paralvsis  is  a disease 
which  commences  in  the  vessel-walls,  and  is  essentially  a slow 
inflammatory  process.  For  proof  of  this  he  points  to  Greppin’s 
.case,  in  which  no  lesions  of  the  nerve-fibres  were  discovered  and 
5 0 nedmann  s case,  in  which  the  nervous  lesions  were  not  at  all 
proportionate  to  those  of  the  vessel-walls,  which  were  very  pro- 
nounced  Experiments  were  carried  out  with  the  express  object 
>of  detecting  the  anatomo-pathological  process  underlying  progres- 
jsive  paratysis  at  its  beginning.  These  consisted  of  the  proUction 
tef  repeated  cerebral  congestions  by  placing  animals  (dogs)  on  a 
durn-taDle,  with  the  head  towards  the  periphery  and  the  posterior 
quarter  towards  the  central  axis,  so  that,  by  imparting  a swift 
TO  atory  movement  to  the  table  a state  of  congestion  was  pro- 
|voked  by  centrifugal  force.  Mendel  by  this  method  succeeded  in 

Tfu""  abundance  of  nuclei  on  the  vessel-walls, 

■ atation  of  the  adventitial  spaces,  accumulation  of  nuclei  within 
the  spaces,  but  no  alterations  either  in  the  white  bundles  or  in  the 


8i6 


PSYCHIATRY 


! 


cells.  Mendel’s  views  are  shared  by  many  others,  including  Gerdes,  : 
who  produced  progressive  paralysis  experimentally  in  dogs,  and 
found  the  most  conspicuous  changes  to  consist  of  thickening  of  the 
intima  and  muscular  coat  of  the  arteries,  and  marked  migration 
of  nuclei.  Bevan  Lewis  maintains  that  the  inflammatory  process  , 
commences  with  a proliferation  of  the  cells  of  the  adventitia,  more  ‘ 
intense  in  the  external  layers  of  the  gray  substance.  i 

According  to  Stanziale  (unpublished  researches  carried  out  in 
my  Clinique),  the  most  profound  alterations  are  found  in  the  vessels  ij 
in  the  form  of  endarteritis  and  periarteritis,  and  these  alterations 
are  indicative  of  the  syphilitic  origin  of  the  malady.  | 

Although  this  doctrine  is  supported  by  facts  of  great  value,  | 
such  as  those  referred  to  above,  it  nevertheless  meets  with  con- 
siderable opposition.  Zacher,  for  example,  found  a marked  degree  I 
of  atrophy  of  the  nerve-fibres,  and  very  few  vascular  lesions  in  i 
two  cases  where  death  occurred  four  and  eight  weeks  from  the  com- 
mencement. My  researches  and  those  of  D’  Abundo  and  Colella 
have  confirmed  the  existence  of  parenchymatous  degeneration  of 
the  peripheral  nerves  independent  of  the  vascular  lesions.  Awtow- 
kratow  has  carried  out  very  minute  investigations  into  the  altera- 
tions of  the  cells  in  the  nuclei  of  the  medulla  oblongata.  His  results 
resemble  in  the  main  those  found  by  Mirzejewski,  Alendel,  Lu-  ■ 
bimow,  and  Butzelsky  in  the  cells  of  the  cortex,  not  only  when 
there  were  marked  vascular  lesions,  but  where  the  vessels  were 
simply  dilated — that  is  to  say,  the  degeneration  of  these  cells  is  ' 
parenchymatous  and  primary. 

'Hermanides  [Les  affections  parasyphilitiqnes,  Haarlem,  1903) ; 
has  attempted  to  reconcile  the  two  doctrines  by  suggesting  that  in 
true  progressive  paralysis  the  lesions  commence  in  the  nerve-elements, 
whilst  the  syphilitic  pseudo-paralysis  always  depends  upon  an 
arteritis.  No  proof  has  been  given  of  this  doctrine,  which  has  also  . 
been  advanced  by  Strumpell  and  Monakow.  The  question  must  j 
still  be  regarded  as  an  open  one.  '■ 

No  less  important  is  the  indication  of  the  localization  of  the,j| 
process  by  means  of  the  succession  of  symptoms.  Here  consider- ; 
able  value  is  to  be  attached  to  the  investigations  of  Buys  and 
Tuczeck,  as  well  as  to  those  of  Binswanger,  who  found  alteration  or  ; 
disappearance  of  the  fibres  of  the  external  la\^er  of  the  convolutions,  ; 
especially  in  the  frontal  lobe  and  in  the  insula.  | 

The  different  localization  of  the  process  and  its  different  in-  1 
tensity  in  the  various  cortical  zones  or  in  the  spinal  cord  explain  , 
the  initial  differences  in  symptomatology,  as  remarked  by  Schafer, 
and  are  related  to  the  innate  predisposition,  and  to  the  different 
measure  and  dignity  of  work  in  the  various  cerebral  provinces  in 
different  men. 

The  rapid  mental  decay  of  paralytics  must  depend  more  on 
lesions  of  the  cells  and  of  the  commissural  bundles  than  on  vascular 


DEMENTIA  PARALYTICA 


817 

lesions.  Whole  bundles  of  nerves  disappear  through  degeneration 
and  reabsorption,  as  though  by  a process  of  digestion  (Lubimow).  - 

.Etiology. — It  is  very  well  known  that  Fournier  at  first  regarded 
progressive  paralysis  to  be  syphilitic  in  genesis,  and  later  on  of  a 
parasyphilitic  nature.  All  are  not  agreed  on  this  point.  This 
dispute  has  presented  many  phases,  and  has  been  productive  of  a 
great  variety  of  statistics. 

The  first  period  is  characterized  by  the  hypothesis  that  progres- 
sive paralysis  is  of  syphilitic  origin  and  nature.  This  doctrine 
aroused,  especially  in  France  and  Germany,  the  hopes  and  dreams 
that  mercurial  treatment  might  prove  of  service  in  combating  this 
inexorable  disease.  The  second  period  is  characterized  by  the 
stimulation  to  a more  accurate  observation  of  the  facts.  The  dream 
of  the  mercurial  cure  of  progressive  paralysis  commences  to  be 
dissipated,  it  is  not  the  syphilitic  virus  that  determines  the  pro- 
cess underlying  progressive  paralysis,  but  the  toxines  that  arise 
secondarily,  following  the  penetration  of  the  syphilitic  virus  into 
the  organism  (Strumpell’s  parasyphilis).  We  might  call  this  the 
parasyphilitic  period.  The  third  period  is  the  present,  resembling 
the  former  in  general  lines,  but  manifesting  a certain  air  of  scepticism 
with  regard  to  the  still  undemonstrated  and  altogether  hypothetical 
toxines. 

Even  recent  statistics  show  the  same  contradictory  features  as 
from  the  very  outset  have  characterized  this  question.  They  show 
an  extremely  varying  percentage  in  syphilitic  origin,  ranging  from 
no  less  than  ii  per  cent,  to  94  per  cent. 

Greidenberg  (‘  Zur  Statistik  und  Aetiologie  der  allgemeinen  pro- 
gressiven  Paralyse  der  IrrenP  N eurologisches  Centralhl.,  1897)  has 
found  syphilis  alone  in  36  per  cent,  of  his  cases,  in  combination  with 
other  causes  in  62*6  per  cent.  In  comparison  with  this  percentage 
of  paralytics  of  syphilitic  origin,  we  have  alcohol  figuring  alone  in 
14-3  percent.,  combined  with  other  causes  in  40  per  cent. ; heredity 
alone  in  47  per  cent.,  combined  in  20-8  per  cent.  ; moral  troubles 
alone  in  87  per  cent.,  combined  in  9 per  cent.  ; traumata  alone  in 
4-3  per  cent.,  combined  in  5-2  per  cent. 

Of  287  paralytics  confined  in  the  Hudson  River  State  Hospital, 
Peterson  found  only  55  with  certain  previous  syphilis ; but, 
as  he  could  not  exclude  it  with  certainty  in  a certain  number  of 
patients,  he  has  raised  his  figure  to  60  per  cent. 

He  found  syphilis  7-1  per  cent,  times  more  frequent  in  pro- 
gressive paralysis  than  in  the  other  psychoses;  but  as  in  30-1  per 
cent,  of  these  patients  neither  hereditary  nor  acquired  syphilis 
could  be  demonstrated,  he  concluded  that  syphilis  is  to  be  regarded 
9-s  a frequent  but  not  constant  cctiological  factor  of  progressive 
paralysis,  and  that  this  disease  is  not  specific,  but  arises  from  the 
action  of  various  aetiological  agents,  preferably  in  individuals  whose 

52 


8i8 


PSYCHIATRY 


constitution  has  been  weakened  by  a previous  syphilitic  infec- 
tion. 

Amongst  227  paralytics  (193  men  and  34  women)  Knudt  found 
syphilis  positive  in  only  16  men,  probable  in  other  8 — that  is  to  say,  i 
in  12*7  per  cent.  The  proportion  was  less  in  the  women,  in  only 
3 of  whom  was  it  certain,  and  in  2 probable — that  is  to  say,  in 
II  per  cent.  Again,  alcohol  was  the  exclusive  cause  in  15  men, 
while  in  41  it  was  combined  with  other  aetiological  factors.  On  the 
other  hand,  hereditary  taint  was  found  in  30  per  cent,  of  the  men 
and  50  per  cent,  of  the  women. 

With  these  examples  I have  sought  to  prove  that  even  in  the 
most  recent  times  the  contradictory  character  of  the  statistics  has 
not  been  corrected,  and  allows  of  no  sure  conclusion  being  drawn 
from  them,  when  we  reflect  that  the  percentage  of  syphilitics  ranges  j 
from  21*6  per  cent.  (Obersteiner)  to  42  per  cent.  (Cullerre),  48-1  per  I 
cent,  to  92-6  per  cent.  (Urquhart),  51  per  cent.  (Jastrovitz),  64  per  1 
cent.  (Cristiani),  74  per  cent.  (Mendel),  77-7  per  cent,  to  96-6  per  cent.  | 
(Carbini),  88  per  cent.  (Minor),  76-7  per  cent.  (Kowalewski),  94  per  | 
cent.  (Regis).  ! 

One  can  understand  how,  by  introducing  the  doubtful  cases  | 
which  go  to  increase  the  numbers  of  true  and  probable  syphilitics  | 
we  are  merely  generalizing,  drawing  argument  from  the  uniformity  , 
of  the  clinical  picture.  Thus,  at  the  Psychiatric  Congress  held  in  | 
Vienna  a few  years  ago,  Hirsch  arrived  at  the  very  strange  conclu-’' 
sion  that,  as  progressive  paralysis  always  presents  itself  in  a well- 
recognisable  clinical  picture,  and,  on  the  whole,  shows  a uniformity;! 
with  regard  tc  the  multiplicity  of  the  presumed  causes,  and  since  in  • 
some  cases  we  can  trace  the  syphilitic  genesis,  we  ought  therefore  to 
conclude  that  to  the  uniformity  of  the  clinical  picture  there  is  a'] 
corresponding  unity  of  genesis  which  cannot  be  other  than  syphilitic  | 
in  every  case. 

I also  present  a few  statistics.  I have  thought  it  advisable  to. 
deal  only  with  those  cases  in  which  it  was  possible  to  obtain  a very, 
detailed  account,  especially  of  the  previous  history.  The  number  of  j 
such  clinical  histories  has  been  87.  In  this  number,  syphilis^ 
has  been  found  only  47  times.  It  must  be  noted  that  syphilis,' 
is  ‘almost  always  accompanied  by  other  causes,  so  that,  wereSi 
we  to  judge  the  individual  cases  very  strictly,  we  would  find 
syphilis  alone  in  very  rare  instances.  In  the  87  cases,  in 
fact,  syphilis  has  only  12  times  been  the  exclusive  cause,  while 
in  35  it  has  been  found  in  combination  with  other  causes — a 
fact  that  greatly  detracts  from  the  value  of  the  h^^pothesis  of  tne 
syphilitic  genesis  of  the  disease.  It  is  important  to  note  that  very 
often  I have  met  with  the  abuse  of  alcohol,  neuro-psychopathic 
heredity,  and  venereal  excesses. 

The  results  of  my  statistics  are  grouped  in  the  following  table  : j 


DEMENflA  PARALYTICA  819 


Total  Number  i 
of  Cases  in  j 

which  Pre-ent. 

As  Sole 
Cause. 

Alon^  with  : 

Other  Causes. 

! 

1 

Observations. 

Heredity... 

48 

1 

1 

17  31 

Syphilis 

47 

35 

Alcohol 

26 

2 24 

Sexual  excesses  ... 

I4 

— 14 

Mental  worry 

9 

I 8 

Five  times  in  women 

Previous  psychopathy  ... 

3 

t ^ 

Previous  neuropathy  

4 

I 3 

Malnutrition 

5 

— 1 

Trauma  ... 

I 

— I 

Isolation  ... 

I 

— [ 

Chronic  intestinal  disturbances 

3 

— 1 3 

Tobacco  ... 

2 

— 2 

Acute  infective  diseases 

5 

— ^ 5 

With  regard  to  the  abuse  of  alcohol,  a very  accurate  investigation 
carried  out  quite  recently  has  shown  that  its  importance  is  far 
from  insignificant  even  in  the  central  provinces  of  Italy.  In  26 
out  of  87  cases,  indeed,  I have  been  able  to  verify  the  abuse  of 
alcoholic  drinks,  a fact  which  agrees  with  the  observations  made  by 
Seppilli  and  his  assistant  Dr.  Lui  in  the  asylum  at  Brescia  (Annali 
di  Neurologia,  1900). 

Ibis  is  also  in  agreement  with  the  views  of  other  observers,  such 
as  Mendel  [Die  Progressive  Paralyse  der  Irren)  ; Greidenberg,  who 
places  alcohol  after  syphilis,  in  the  proportion  of  14-3  per  cent,  as  the 
exclusive  cause,  and  40  per  cent,  combined  with  other  causes  ; Van 
Deventer  (‘  Twee  gevallen  van  Dementia  Paralytica'  etc..  Psych,  en 
Neurol.  Bladen,  1898),  who  places  the  abuse  of  alcoholic  liquors  in 
the  first  rank  ; Knudt,  who  amongst  193  paralytics  found  alcohol  as 
an  exclusive  cause  of  the  malady  in  15  cases,  and  combined  with 
other  aetiological  factors  in  41  cases ; Funaioli,  and  very  many  others. 

W e cannot  fail  to  recognise,  then,  in  the  abuse  of  alcoholic 
drinks  a genetic  agent  of  progressive  paralysis  almost  equal  in  power 
to  syphilis. 

It  has  been  affirmed  by  many  authors  that  this  malady  is  the 
least  hereditary  of  the  psychopathies,  and  that  it  develops  under  the 
influence  of  causes  that  act  on  the  individual  independently  of 
hereditary  predisposition  ; but  both  accurate  examination  of  the 
literature  of  the  subject  and  direct  observation  bring  into  evidence 
the  fact  that  heredity  is  much  more  frequent  than  is  generally  sup- 
posed. Amongst  87  cases,  heredity  figures  17  times  as  the  sole  cause 
5 of  the  disease,  and  48  times  combined  with  other  causes.  Whilst 
syphilis  is  found  alone  in  12  cases,  heredity  occurs  alone  in  17  ; 
this  demonstrates  the  value  of  hereditary  taint. 

I leave  unprejudiced  the  question  whether  hereditary  syphilis 

52—2 


820 


PSYCHIATRY 


plays  any  great  part  in  these  cases,  as  held  by  many  of  the  French 
school. 

Heredity  hgures  to  a small  extent  in  the  statistics  of  Greidenberg 
and  of  Westphal  Aetiologisches  und  symptomatologisches  zur  Lehre 
von  dcr  Prog.  Par.  der  Irren.p  Neurolog.  Centralh.,  1894).  In  the 
former  we  find  it  as  an  exclusive  cause  in  4-7  per  cent.,  and  along 
with  other  causes  20-8  per  cent.  ; in  th^  latter  the  percentage  is 
5*4  per  cent. 

In  an  accurate  statistical  study  of  238  patients  in  the  Sainte  Anne 
Clinique,  Ameline  found  that  heredity,  of  one  or  other  degree  (double, 
single,  partial,  alcoholic,  and  vesanic  or  similar),  may  be  regarded  as 
present  without  doubt  in  half  the  cases  (‘  De  VheredMe  et  en 
particulier  de  Vheredite  similaire  dans  la  paralysie  ghiHale"  Ann. 
Med.  Psych.,  1899).  It  serves  but  little  purpose  to  take  up  the 
question  whether  the  children  of  paralytics  are  liable  to  progressive 
paralysis,  nor  can  we  regard  it  as  a fruitful  subject  of  discussion, 
as  has  been  carried  on  by  Arnaud,  Briand,  Charpentier,  Joffroy,  and 
Christian  (p  A propos  de  la  descendance  des  par alytiq^ues  generaux, 
Ann.  Med.  Psych.,  1899).  In  this  respect  progressive  paralysis 
behaves  like  all  other  mental  and  nervous  affections. 

That  heredity  exercises  a great  pathogenic  influence  is  also  con- 
firmed by  the  observations  of  Naecke,who  assigns  a preponderating 
influence  to  heredity  and  degeneration  in  the  development  of  pro- 
gressive paralysis  Dementia  Paralytica-  und  Degeneration,  N eurolog. 
Centralh.,  1898-1900). 

Further,  progressive  paralysis  from  heredity  is  closely  related 
with  apoplexy  in  the  genitors.  In  the  collection  of  87  cases, 
it  was  found  that  at  least  in  10  instances  the  genitors  were 
hemiplegic  or  had  died  from  apoplexy.  The  heredity  was  strongest 
where  both  parents  had  suffered  from  paralysis,  no  matter  whether 
due  to  thrombosis  or  to  cerebral  hemorrhage.  In  these  cases  it  is  not 
a mere  coincidence  that  we  have  to  deal  with,  as  Stoddart  subtly 
suggested  apropos  of  cases  of  paralytics  whose  parents  had  both  been 
paralytic,  or  else  one  paralytic  and  the  other  tabetic. 

Again,  it  is  to  be  noted  that  the  apoplectic  or  apoplectiform 
attacks  in  paralytics,  especially  at  the  commencement  of  the  disease, 
as  not  infrequently  occurs,  are  sometimes  connected  with  the 
presence  of  renal  disease.  Bristowe  has  put  on  record  his  observa- 
tions of  75  cases  of  progressive  paralysis,  in  60  of  which  he 
found  nephritis.  I can  add,  in  confirmation  of  Bristowe’s  obser- 
vations, that  renal  lesions  are  frequently  found  at  the  autopsies 
made  in  the  Naples  Asylum.  Albumin  is  frequently  present  in  the 
urine,  and  the  kidneys  are  generally  found  to  be  small  and  atrophied. 
In  20  recent  autopsies  the  kidneys  presented  more  or  less  profound 
changes  in  13  instances. 

In  many  cases  of  paralysis  in  which  the  disease  has  commenced 
with  an  apoplectiform  attack,  the  examination  of  the  urine  has 


DEMENTIA  PARALYTICA 


821 


i revealed  the  presence  of  a marked  degree  of  nephritis.  In  some  of 
I these  cases  the  patients  had  shown  no  sign  of  the  malady  before  the 
J apoplectiform  (uraemic  ?)  attack. 

j These  observations  apply  both  to  syphilitic  subjects  and  to  those 
I in  whom  we  can  absolutely  exclude  syphilis. 

If  alongside  the  relationship  traced  between  apoplexy  in  the 
. genitors  and  progressive  paralysis  in  the  offspring  we  place  that 
between  nephritis  and  progressive  paralysis,  and  also  that  between 
» previous  apoplexy  and  the  later  onset  of  progressive  paralysis  in 
the  same  individual,  and  if,  at  the  bottom  of  this  series  of  facts,  we 
f could  recognise  the  arthritic  diathesis  which  is  regarded  by  the 
majority  of  pathologists  as  the  cause  of  vascular  alterations,  we 
might  more  reasonably  assign  to  the  arthritic  state  a high  pathogenic 
value. 

Long  ago  I came  to  this  conclusion,  which  I have  seen  confirmed 
in  the  excellent  examination  of  the  question  made  by  Mairet  and 
Vires  (‘ la  paralyse  generale  : Etiologie,  pathogenie,  traitementP 
1898),  who  attribute  great  importance  to  the  arthritic  heredity, 
as  set  forth  by  Bouchard,  and  also  to  the  alcoholic  heredity,  whilst 
they  assign  a rather  low  value  to  syphilis. 

Previous  simple  psychoses  act  by  preparing  the  soil  for  the  de- 
velopment of  progressive  paralysis.  There  are  patients  who,  years 
before,  have  suffered  from  an  attack  of  melancholia,  or,  as  more 
commonly  happens,  of  mania.  After  an  interval  of  five  to  eight 
years,  the  second  attack  takes  the  form  of  paralytic  dementia.  It 
would  be  impossible  to  predict  that  the  first  attack  represents  a 
prelude  to  the  succeeding  morbid  picture.  Again,  there  are  cases  of 
progressive  paralysis  that  arise  in  the  train  of  another  uncured 
i mental  disorder.  Amongst  other  cases,  I remember  a paranoiac  who 
had  been  ten  years  in  the  asylum.  She  was  a chronic  patient,  and 
. only  after  this  long  duration  of  the  primary  affection  did  the  sympto- 
matic picture  of  progressive  paralysis  arise,  the  patient  dying  of  the 
latter  disease. 

Another  case  was  that  of  a syphilitic  young  man,  suffering 
from  a classic  form  of  sensory  insanity,  followed  by  stupor,  which 
i lasted  several  months.  Improvement  had  commenced,  and  the 
' patient  seemed  well  on  the  road  to  recovery,  when  suddenly  the 
stupor  ceased,  a delirium  of  grandeur  was  set  up,  and  a galloping 
form  of  progressive  paralysis  became  established. 

At  the  autopsy  all  the  signs  of  progressive  paralysis  were  found. 
The  most  probable  theory  is  that  the  progressive  paralysis  did  not 
arise  as  a disease  by  itself,  but  was  a secondary  development  in  a 
Train  that  had  already  undergone  the  pernicious  effects  of  a pre- 
j ceding  intoxication  which  had  produced  the  primary  hallucinatory 
) psychosis. 

i Previous  attacks  of  insanity,  of  any  form  whatsoever,  disturb 
I the  nutritive  processes  in  the  nerve-cell  which,  immediately  follow- 


822 


PSYCHIATRY 


ing  the  psychosis  or  after  a longer  or  shorter  time,  degenerates. 
Herein  lies  the  explanation  of  the  development  of  progressive 
paralysis  after  acute  infective  diseases  (cases  of  Dalmar  and  others), 
including  pellagra  (Baillarger,  Lombroso,  and  Pianetta,  La  de- 
mentia paralytica  nei  pellagrosi,  1900). 

The  same  explanation  must  apply  to  those  cases  of  juvenile 
progressive  paralysis  in  which  tuberculosis  was  the  only  discover^ 
able  antecedent  (Marchand,  Regis). 

Strlimpell  and  others  have  affirmed  that  progressive  paralysis 
develops  in  the  tertiary,  and  Joffroy  in  the  quaternary,  period.  It 
would  accordingly  be  included  amongst  the  parasyphilitic  affections. 
This  is  deduced  from  the  fact  that  no  syphilitic  lesions  are  found 
at  the  autopsy,  and  from  the  negative  therapeutic  results,  for  it  is 
now  generally  recognised  that  antisyphilitic  remedies  are  of  no 
service. 

The  hypothesis  of  the  specificity  of  the  parasyphilitic  toxines 
(syphilotoxines  of  Striimpell  and  Moebius,  indirect  alexines  of 
Finger,  included  by  Tommasoli  under  the  happy  term  of  syphilism) 
in  the  genesis  of  progressive  paralysis  would  be  belied  did  there 
exist  cases  in  which  tabes  dorsalis  or  progressive  paralysis  developed 
during  the  period  of  efflorescence  of  the  secondary  syphilis.  Now, 
cases  of  this  kind  are,  indeed,  to  be  found  in  the  literature  of  the 
subject,  and  I have  myself  observed  several.  At  a recent  congress 
in  Limoges,  Devay  referred  to  such  cases,  and  was  supported  by 
Ballet  and  Brissaud.  These  observers,  however,  have  not  been 
able  to  record  a shorter  interval  than  three  years  between  the 
inoculation  of  the  syphilitic  virus  and  the  onset  of  progressive 
paralysis.  I can  say  with  certainty  that  I have  observed  many 
cases  in  which  it  was  impossible  to  speak  of  parasyphilis,  but  rather 
of  syphilis,  the  disease  having  commenced  only  a few  months  after 
the  contagion.  Very  often  it  happens  that,  during  the  amtisyphilitic 
treatment,  soon  after  the  ulcer  has  healed,  and  sometimes  even 
earlier,  the  patient  complains  of  pains,  which  are  mistaken  for 
osteocopic  pains,  but  are  in  reality  the  pseudo-neuralgic  pains 
that  indicate  the  commencement  of  tabes.  Later  on  the  phenomena 
of  dementia  paralytica  enter  upon  the  scene.  These  two  syndromes 
cannot  be  regarded  as  distinct  from  one  another  ; they  constitute 
only  one  disease.  There  is,  then,  no  doubt  that  the  conditions  that 
determine  the  development  of  progressive  paral3^sis  may  be  realized, 
not  only  in  the  tertiary  and  quaternary,  but  also  in  the  secondary 
periods  of  syphilis. 

There  are  cases  in  which  the  classic  manifestations  of  tertiary 
syphilis  exist  along  with  progressive  paralysis.  By  means,  however, 
of  the  antisyphilitic  remedies,  the  gummata  and  all  the  other  mani- 
festations of  general  syphilis  disappear,  and  the  progressive  paralysis 
continues  its  fatal  course  without  undergoing  any  modification  from 
the  more  or  less  prolonged  treatment. 


DEMENTIA  PARALYTICA 


823 


I All  these  facts  lend  greater  probability  to  Hitzig’s  hypothesis, 
- according  to  which  other  toxines  sometimes  act  along  with  the 
i syphilitic  virus,  modifying  the  state  of  the  blood  in  some  particular 
way,  and  predisposing  to  the  degeneration  of  the  nervous  system. 

I It  is  to  be  added  that,  whilst  nearly  all  prostitutes  are  syphilitic, 
progressive  paralysis  is  very  rare  amongst  them,  while  it  is  frequent 
i in  married  women,  syphilitic  or  not.  This  is  a fact  of  the  greatest 
I significance,  and  it  is  confirmed  by  similar  observations.  Amongst 
^ 565  paralytic  women,  Idanow  found  only  83  prostitutes. 
Wollemberg  and  Westphal  obtained  very  similar  results.  Wollem- 
berg  declares  that  the  majority  of  paralytics  are  married,  and  that 
prostitution  makes  but  a small  contribution  to  their  number. 
Siemerling  also  agrees  with  this. 

Westphal  was  surprised  to  find  that  among  148  paralytics  there 
was  not  a single  prostitute.  This  is  a point  I remarked  in  1887, 
apropos  of  the  aetiology  of  tabes.  From  1891  to  1898,  Sanna  Safaris 
observed  only  two  paralytic  women  in  the  asylum  at  Cagliari,  and 
it  cannot  be  said  that  prostitution  and  syphilis  do  not  exist  in 
Sardinia. 

Progressive  paralysis  sometimes  develops  before  syphilis.  Cases 
have  been  reported  where  paralytics  have  been  discharged  from  the 
asylum  during  a period  of  remission,  and  have  contracted  syphilis 
(Greidenberg).  It  may  be  objected  that  syphilis  is  capable  ot 

I being  inoculated  a second  time,  but  such  facts  at  least  counter- 
balance the  results  of  Krafft-Ebing’s  experiments,  which,  though 
certainly  very  bold,  are  yet  not  very  demonstrative.  Krafft-Ebing 
: inoculated  paralytics  with  syphilitic  virus,  but  found  them  immune, 
;and  argued  accordingly  that  all  those  paralytics  were  already 
syphilized,  forgetting  to  take  into  account  the  fact  that  immunity 
to  syphilis  is  very  frequent. 

It  is  well  to  add  that  there  is  no  clinical  difference  between 
; syphilitic,  alcoholic,  and  other  non-syphilitic  paralytics.  At  any 
rate,  amongst  many  hundreds  of  paralytics  I have  never  been  able  to 
j establish  any.  Differences  in  the  symptomatic  picture  do  not 
j depend  upon  differences  in  the  causes  that  have  determined  the 
^ disease.  All  distinctions  made  up  till  now  have  been  artificial. 
The  groups  of  hereditary  paralysis,  syphilitic  paralysis,  and  alcoholic 
paralysis  all  present  the  same  mode  of  commencement  and  the 
same  course.  That  syphilis  is  one  of  the  causes  of  progressive 
paralysis  admits  of  no  doubt,  but  we  cannot  consent  to  the  hypo- 
thesis that  it  is  the  specific  pathogenic  factor.  The  abuse  of  alcohol, 
the  arthritic  diathesis,  heredity,  sexual  excesses,  mental  worry,  sun- 
stroke, moral  sufferings,  and  injuries  to  the  head,  are  able  to  deter- 
|mine  the  same  degenerative  process  in  the  nerve-elements  or  the 
'Vessel-walls,  especially  when  congenital  weakness  of  the  nervous 
'System  is  present.  In  all  this  there  is  nothing  specific. 

Its  biochemical  orientation  and  activity  being  altered,  the 


I 


824 


PSYCHIATRY 


I 


nerve-element  is  less  capable  of  defence,  and  dies  earlier  in  the  ' 
ordinary  course  of  life.  It  is  no  longer  able  to  take  up  the  quantity  ; 
of  nourishment  necessary  for  its  existence,  and,  above  all,  to  promptly  ; 
eliminate  the  products  cf  its  disintegration,  but  remains  in  a condi-  I 
tion  of  katabolism. 

Nor  are  we  even  in  a position  to  invoke  for  progressive  paralysis  I 
the  facts  that  have  been  specially  brought  forsvard  in  recent  times  I 
in  the  case  of  tabes  dorsalis.  We  know  that,  to  strengthen  the  i 
notion  of  pseudo-tabes,  there  have  been  recorded  cases  diagnosed 
as  tabes  dorsalis,  in  which,  at  the  autopsy,  a specific  meningitis, 
with  formation  of  gummatous  nodules,  has  been  found,  in  addition 
to  the  lesions,  systematized  or  not,  of  the  posterior  columns. 
These  are  the  cases  of  Kuh,  Ewald,  Dinkier,  Marinesco,  Eisenlohr, 
Oppenheim,  Brusch,  and  others.  Now,  the  leptomeningitis,  and  | 
sometimes  the  pachymeningitis,  that  are  almost  constantly  found  | 
at  the  autopsy  of  paralytics  hardly  ever  present  the  characters  of 
syphilitic  meningitis  and  gummatous  nodules.  | 

Progressive  paralysis,  then,  is  not  a specific  disease  like  tuber- 
culosis, syphilis,  or  small-pox,  but  may  be  provoked  by  a large 
number  of  causes.  Syphilis,  alcohol,  heredity,  moral  or  physical 
injury,  sexual  abuse,  apoplexy,  nephritis,  and  previous  mental 
affections,  all  prepare  a particular  biochemical  (toxic)  condition, 
which  lowers  the  nutritive  energy  of  the  nerve-elements,  and 
favours  the  final  victory  of  the  connective  elements. 

Thus  only  can  we  explain  the  complex  uniformity  of  the  ; 
clinical  figure  and  the  pathological  anatomy  of  the  paralysis,  until 
new  facts  are  discovered  showing  that  all  these  causes  do  not  prepare 
thejsoil  for  a single  intoxication,  microbic  or  otherwise.  Robertson 
(with  MacRae  and  Jeffrey),  has  carried  out  important  researches  , 
bearing  upon  this  question  (‘  Bacteriological  Investigations  into  the 
Pathology  of  General  Paralysis  of  the  Insane,’  Review  of  Neurology 
and  Psychiatry,  1903).  This  distinguished  observer  found  the  Klebs-  ; 
Loffler  bacillus  of  diphtheria  so  often  and  in  such  abundance  in  the  . 
digestive  and  respiratory  apparatus,  and  even  in  the  brain  (in  four  ^ 
out  of  sixteen  paralytics),  that  he  could  not  deny  that  it  had  a ■ 
high  value  in  the  pathogenesis  of  general  paralysis.  The  conclusion  ! 
to  be  drawn  is  that  the  power  of  resistance  to  the  attacks  of  this  ' 
micro-organism  is  lowered  by  the  action  of  syphilis,  alcohol,  and 
all  other  alleged  causes  of  general  paralysis.  We  hope  that  the 
interesting  facts  brought  to  light  by  Robertson  may  be  conhrmed, 
and  that  a more  legitimate  field  for  the  therapy  of  this  disease  may 
thus  be  opened. 

Ethnic  conditions,  so  closely  connected  as  they  are  with  the 
mode  of  living,  must  not  escape  examination  in  the  question  of  the 
genesis  of  progressive  paralysis.  iMuch  light,  in  fact,  may  be 
derived  from  this  examination.  It  cannot  be  disputed,  judging 
from  the  reports  of  Lowes,  Henger,  and  Meilhon,  that  progressive 


*}  DEMENTIA  PARAEYTICA  825 

f paralysis  is  rare  among  the  Arabs  and  amongst  Mussulmans  in 
t general ; rare  also  in  Servia,  in  Southern  Russia,  in  some  districts 
of  Scotland,  and  in  Ireland  (Macpherson).  The  same  remark  may 
also  be  applied  to  Switzerland.  There  is  no  doubt  that  syphilis  is 
I rare  in  the  cold  regions,  such  as  Iceland,  only  four  cases  having 
been  observed  in  eight  years  by  Schieberck,  the  principal  medical 
j officer  of  that  region,  while  at  the  same  time  progressive  paralysis  is 
; very  rare,  that  officer  having  observed  only  one  case  ; but  it  is  to  be 
remembered  that  syphilis  is  very  frequent  in  Japan,  whilst  general 
paralysis  is  rare  (2  per  cent,  in  the  Tokio  Asylum  a few  years  ago). 
We  must  add  that  it  is  rare  also  in  x\byssinia.  Now,  if  this  is  true, 
although  it  is  disputed  by  Ballet,  who  throws  out  the  suspicion  that 
! progressive  paralysis  is  not  so  very  rare  amongst  the  Arabs,  the 
1 doctrine  of  the  specific  genesis  of  progressive  paralysis  cannot  be 
! held  to  be  assured,  for,  as  is  well  known,  syphilis  is  quite  common 
i and  very  severe  amongst  those  peoples.  Even  Bukley,  cited  by 
I Cullerre,  attributes  the  progressive  paralysis  observed  amongst 
I negroes  to  the  rapid  change  in  mode  of  living  of  the  negro  race, 

! which,  formerly  exempted  from  the  preoccupations  of  daily  life, 

I now  finds  itself  engaged  alongside  civilized  races  in  the  struggle 
\ for  existence.  E.  Stoddart  holds  general  paralysis  to  be  essentially 
i a disease  of  civilization,  and  affirms  that  it  is  practically  unknown 
^ among  the  uncivilized  nations  of  the  world.  One  would  like  to 
know  of  what  civilization  Stoddart  means  to  speak.  In  the  pro- 
I vince  of  Naples,  not  more  civilized  than  Turin,  the  paralytics  are 
I in  the  average  proportion  of  30  per  cent,  of  the  men  sent  to  the 
if  asylum. 

I 

I . . 

j Diagnosis.  An  accurate  examination  of  a paralytic  allows  us 
to  recognise  progressive  paralysis  with  certainty  when  the  disease 
is  conhrmed,  and  to  distinguish  it  from  all  other  psychopathies  and 
I organic  diseases  of  the  brain. 

I It  is  distinguished  from  cerebral  syphilis  by  the  fact  that  in 
1 syphilis  of  the  brain  the  somatic  phenomena  are  more  limited  and 
i defined  (ocular  paralysis,  hemiplegia,  very  intense  but 

j limited  cephalalgia,  neuralgia  of  the  trigeminus,  with  atrophy  and 
^ disappearance  of  the  temporal  muscles,  associate  paralysis  of  the 
external  rectus,  crossed  paralysis),  while  the  psychic  phenomena 
are  but  slightly  marked  or  entirely  absent.  In  the  few  cases  in 
which  there  is  a diffuse  gummatous  formation  along  the  course  of 
, the  arteries,  syphilis  assumes  all  the  characteristics  of  dementia 
paralytica  (Hugues).  In  these  very  rare  cases  the  differential 
diagnosis  is  impossible.  The  difficulties  are  somewhat  increased 
j in  the  first  stage  of  the  disease,  and  in  this  matter  I share  the  pre- 
I occupation  of  Eolsom  and  others  ; but  even  in  this  stage  accurate 
I examination  of  the  behaviour  of  the  patient,  especially  when  we 
lare  dealing  with  a well-organized  individual  of  high  intellectual 


826 


PSYCHIATRY 


development,  who  presents  phenomena  of  mental  decadence, 
generally  succeeds  in  overcoming  them. 

I have  never  been  able  to  find  a place  for  pseudo-paralysis 
amongst  my  convictions,  and  I must  declare  that  amongst  a very 
large  number  of  observations  of  progressive  paralysis  I have  never 
come  across  any  of  the  so-called  pseudo-paralyses.  I therefore 
hold  syphilitic  pseudo-paralysis  to  be  simply  a clinical  variety. 

Progressive  paralysis,  be  it  of  alcoholic  or  syphilitic  origin,  admits 
of  no  transitions  ; such  can  happen  only  when  we  are  dealing  with 
any  other  process  that  is  erroneously  and  dangerously  confounded 
with  progressive  paralysis.  It  always  preserves  its  own  significance, 
being  in  no  way  modified  by  the  ‘ pseudo  ’ of  the  lovers  of  lights  and 
shades.  It  always  shows  the  same  want  of  response  to  treatment, 
and  is  almost  always  fatal. 

Some  observers  state  that  delirium  of  grandeur  is  absent  in 
cerebral  syphilis — that  is  to  say,  in  the  so-called  paralysis  from 
end-  and  peri-  arteritis.  This  is  true  only  in  the  case  of  cerebral 
syphilis  with  symptoms  of  foci,  not  in  the  form  characterized  by 
endarteritis. 

Schfile,  Ziehen,  and  Krafft-Ebing  have  attributed  great  im- 
portance to  the  universal  character  of  the  psychic  disturbance  in 
true  general  paralysis,  in  which,  they  maintain,  the  dementia  is 
most  characteristic,  whilst  in  pseudo-paralysis  we  have  rather  a 
defect  in  logic  and  an  arrest  of  thought  (Ziehen),  along  with  somno- 
lence, apathy,  and  hallucinatory  accessions,  which  disappear  and 
give  place  to  mental  lucidity. 

In  progressive  paralysis  we  find  factors  that  are  observed  in 
all  chronic  mental  affections — forms  of  rapid  and  forms  of  slow 
development,  complete  forms  and  rudimentary  and  abortive  forms, 
just  as  in  tuberculosis,  syphilis,  tabes,  etc.  All  this  does  not  justify 
us  in  establishing  the  varieties  of  pseudo-paralysis.  At  the  most 
we  may  speak  of  mild  and  abortive  (rare)  forms. 

Given  the  onset  of  the  disease  with  one  of  the  syndromes  de- 
scribed, and  given  the  slightest  disorder  of  speech  articulation, 
which  sometimes  can  only  be  detected  with  the  greatest  difficulty, 
we  must  make  the  diagnosis  of  general  paralysis,  no  matter  what 
the  form  assumed  or  the  cause  that  gives  rise  to  it.  I have  pre- 
viously mentioned  how  the  excitement  and  delirium  of  mania  can- 
not be  mistaken  for  the  excitement  and  delirium  of  progressive 
paralysis. 

The  delirium  of  grandeur  of  progressive  paralysis,  is  distinguished 
from  that  of  paranoia  of  pride,  in  which,  amongst  other  charac- 
teristics, the  reasoning  power  is  preserved  for  a long  time,  and 
somatic  phenomena  are  definitely  absent.  This  same  feature  will 
serve  to  distinguish  progressive  paralysis  from  melancholia  and 
circular  insanity,  whilst  an  accurate  psychic  examination  will  always 
bring  to  light  the  element  ‘ dementia,’  which  is  not  found  in  melan- 


DEMENTIA  PARALYTICA 


827 


cholia  nor  in  circular  insanity,  except  they  have  been  of  long  dura- 
tion. In  these  affections  articulatory  disturbances  of  speech  are 
always  absent. 

Nor  can  it  be  confounded  with  the  stuporous  state  of  melan- 
cholia, hallucinatory  stupor,  or  dementia  praecox,  when  one  bears 
in  mind  the  almost  exclusive  somatic  phenomena  of  progressive 
paralysis.  Tremor  is  met  with  in  some  rare  cases  of  dementia 
praecox,  but  it  is  very  different  from  that  of  dementia  paralytica. 
Mutism,  negativism,  and  mannerisms  are  exceedingly  rare  phenomena 
in  dementia  paralytica.  Articulatory  disturbances  are  almost 
always  wanting  in  dementia  praecox.  Any  confusion  is  due  to  an 
error  in  diagnosis. 

From  alcohclic  encephalopathy  it  is  distinguished  not  only  by 
the  traces  of  acute  toxic  delirium,  but  also  by  the  fact  that  what 
we  get  in  this  case  is  not  so  much  dementia  as  intellectual  dulness, 
which,  instead  of  being  progressive  as  in  progressive  paralysis, 
tends  to  disappear.  The  disturbances  of  motility  in  the  alcoholic 
encephalopathy  are  ataxic  or  spasmodic  in  nature,  and  arise  tumul- 
tuously. Those  of  dementia  paralytica  are  paralytic  in  nature,  and 
slowly  progressive. 

Hallucinations  and  disturbance  of  general  sensation  are  more 
frequent  in  alcoholism  than  in  paralytic  dementia.  Muscular 
atrophy  depending  upon  neuritis  favours  the  diagnosis  of  alcoholic 
cerebropathy  (alcoholic  paralytiform  insanity  of  Grimaldi). 

From  the  saturnine  encephalopathy  it  is  distinguished  by  the 
general  features  of  lead-poisoning,  which,  just  as  it  may  give  rise 
to  forms  very  similar  to  tabes  (Stieglitz,  Pal,  De  Renzi,  Monakow), 
also  produces  a true  progressive  paralysis  which  cannot  be  distin- 
guished either  by  its  clinical  picture  or  by  its  course  and  issue 
(Maran  on  di  Montyel,  Mendel,  Gowers). 

I have  experienced  real  difficulty  in  two  cases  of  hysteria, 
which  may  sometimes  simulate  the  gravest  spinal  diseases,  and  even 
progressive  paralysis. 

The  course  of  progressive  paralysis  varies  greatly.  There  are 
cases  that  run  an  acute  course,  terminating  in  a few  weeks  or 
months,  or  a subacute  course,  lasting  a year  or  little  more.  Again, 
there  are  cases  whose  entire  development  involves  a period  of  ten 
years  or  longer.  Between  these  two  extremes  there  are  many 
degrees  of  duration.  This  great  variety  in  the  course  depends 
partly  on  the  intensity  of  the  intoxication  and  the  site  chosen  by 
the  disease,  and  partly  on  the  resistance  of  the  individual.  Above 
all,  there  are  episodes,  sometimes  fatal — acute  delirium,  apoplecti- 
form and  epileptiform  attacks — which  not  only  give  a particular 
stamp  to  the  disease,  but  shorten  its  duration. 

A galloping  course  depends  on  causes  that  cannot  always  be 
determined.  Whether  we  have  the  intervention  of  special  infec- 


828 


PSYCHIATRY 


tions,  or  intoxications  arising  from  absorption  of  abnormal  intes-  i 
final  products,  or  the  presence  of  new  products  of  an  altered  tissue 
metabolism  arising  from  hepatic  or  other  glandular  insufficiency, 
are  points  that  further  researches  will  probably  elucidate  at  no 
distant  date. 

We  may  have  in  the  course  of  progressive  paralysis  periods  of 
improvement,  during  which  almost  all  the  somatic  and  psychic 
disturbances  disappear,  sometimes  to  such  an  extent  as  to  simulate  | 
recovery.  There  always  remains  a certain  degree  of  depression  of  ‘ 
the  various  mental  activities,  but  on  the  whole  there  is  established  | 
a condition  that  is  generally  satisfactory  and  very  like  recovery. 

The  psychic  and  somatic  symptoms  do  not  show  a parallel  i 
improvement.  Sometimes  the  latter  persist,  whilst  the  intelligence  | 
seems  to  have  reacquired  its  former  vigour  ; at  other  times  both 
psychic  and  somatic  symptoms  ameliorate,  but  in  most  cases  a 
certain  degree  of  mental  enfeeblement  may  be  recognised. 

Some  observations  go  to  prove  that  remission  in  paralytics  may 
even  exceed  our  expectations  ; the  psychic  personality  becomes 
restored.  A professor  of  music  confined  in  the  Sales  Asylum  with 
the  most  classic  form  of  progressive  paralysis  was  discharged  after 
some  months,  so  much  improved  that  he  was  able  to  lead  the 
orchestra  of  the  Teatro  Mercadante.  There  remained  only  a certain 
slowness  of  thought  and  speech,  and  a slight  depression  of  the  to  e of  _ 
the  psychic  personality,  bordering  on  childishness. 

Another  man,  who  amongst  other  disorders  showed  such  a pro-; 
found  alteration  of  the  kinaesthesis  that  he  confidently  threw  himself . 
from  the  window  of  his  house  because,  he  said,  he  felt  so  light  that 
he  seemed  able  to  fly,  was  discharged  from  the  asylum  as  cured,  ^ 
owing  to  the  complete  disappearance  of  the  psychic  and  somatic  ^ 
phenomena — tremors,  inequality  of  the  pupils,  defective  articula- 
tion, etc.  I might  have  published  this  case  as  a rare  example  of  | 
recovery,  but  this  error  was  prevented  by  the  patient  returning, 
to  the  asylum  about  a year  later,  with  the  same  clinical  picture  as| 
before  ; this  time,  however,  the  malady  proceeded  to  a fatal  issue.  | 

Remissions  are  more  frequent  and  even  more  promising  in  thej 
maniacal  form  of  paralysis,  and  more  so  at  the  beginning  of  thej 
disease  than  at  an  advanced  stage  ; very  rarely,  however,  are  they 
so  complete  as  in  the  case  to  which  I have  referred.  The  lucid  i 
intervals  of  the  circular  form  of  progressive  paralysis  described  by 
Fabre  and  others  have  little  or  nothing  in  common  with'the  remis- ! 
sions  in  question.  These  remissions  sometimes  last  two  (Baillarger), 
and  even  three  years  (Legrand  de  Saulle)  ; this,  according  to  my  | 
experience,  is  a very  rare  occurrence.  ! 

Doutrebente’s  and  Lasegue’s  cases  of  remission,  lasting  twenty- 1 
five  years,  are  at  least  worthy  of  mention,  but  the  same  hesitancy  is 
here  to  be  observed  as  in  the  cases  of  recovery  of  Voisin  and  Schule. 
Although  such  statements  are  guaranteed  by  persons  of  authority, 


DEMENTIA  PARALYTICA 


829 

I I must  confess  that,  excluding  those  remissions  so  closely  resembling 
recovery,  I have  never  observed  a true  case  of  recovery,  notwith- 
I standing  the  numerous  methods  of  treatment  I have  tried.  Nor 
: can  I associate  myself  with  the  statements  of  Morel,  Falret,  and 
I Doutrebente  to  the  effect  that  progressive  paralysis  in  hereditary 
cases  may  last  even  twenty-five  years.  In  this  respect  I share  the 
opinion  of  Marandon  di  Montyel.  The  longest  duration  I have 
observed  in  any  case  has  been  thirteen  years.  The  average  duration 
‘ is  from  three  to  five  years,  the  fatal  issue  being  due  to  apoplectiform 

I and  epileptiform  attacks,  chronic  diarrhoea,  purulent  cystitis,  septi- 
caemia caused  by  bedsores,  pneumonia,  general  marasmus,  etc. 

The  prognosis  is  decidedly  unfavourable.  Even  when,  by  accu- 
rate clinical  inquiry,  the  disease  can  be  detected  at  its  very 
commencement,  the  experienced  clinician  can  indulge  no  hope  of 
j recovery.  In  private  practice  we  meet  with  cases  of  incipient  para- 
j lysis  in  which  the  first  symptoms,  very  indefinite,  disturb  the  con- 
I sciousness  of  the  patient,  or  are  noticed  by  an  observant  family, 

I and  in  these  cases  the  most  favourable  and  rational  conditions  in 
I which  the  patient  can  be  placed  can  at  most  only  hinder  the  ulterior 
I development  of  the  disease,  which  in  every  instance  pursues  an 
I unrelenting  course.  No  doubt  there  is  a prodromal  period  during 
which  the  efforts  of  the  physician  might  bear  fruit,  and  which  may 
j last  many  months,  or  even  a year  or  so  (in  the  neurasthenic  forms) ; 

I but  it  is  almost  impossible  to  recognise  the  true  nature  of  the  pro- 
dromal symptoms— ^.g.,  exaggerated  affective  excitability,  a certain 
degree  of  loss  of  memory  and  incapacity  for  attention,  insomnia, 
headache,  disturbances  of  the  sexual  sphere  (exaggerated  excitability 
or  impotence),  new  tendencies,  such  as  for  alcohol,  etc.,  all  of  which 
phenomena  are  not  at  all  characteristic  of,  or  peculiar  to,  progressive 
paralysis. 

Therapy. — I would  like  to  share  the  hopes — certainly  net  sup- 
ported by  careful  investigation— of  some  authors,  who  hold  that 
.progressive  paralysis  is  curable  at  its  commencement,  on  the  ground 
fthat  we  have  then  to  deal  with  simple  congestion,  which  Brunet 
fasserts  he  has  very  successfully  combated  with  the  tartrate  of  anti- 
mony in  doses  up  to  a gramme,  and  with  bromide  of  potassium  up 
to  40  grammes  (!)  per  day.  Most  unfortunately,  these  statements  are 
not  justified  by  facts. 

Notwithstanding,  the  efforts  of  the  conscientious  clinician,  who 
by  early  recognition  of  the  malady  is  able  to  hinder  its  development, 
may  be  beneficial,  if  not  in  saving  the  patient,  at  least  in  preventing 
the  reckless  and  certain  dissipation  of  fortunes,  sometimes  eolossal, 
and  in  protecting  the  patient’s  family  and  others  from  moral  and 
material  injuries.  Mental  rest,  by  withdrawing  the  patient  from  his 
accustomed  stimuli  and  usual  environment,  and  at  the  same  time 


830 


PSYCHIATRY 


preventing  in  the  most  suitable  way  the  carrying  out  of  his  grandiose  i 
enterprises,  is  the  first  and  most  important  indication.  j 

From  the  very  outset  the  exalted  paralytic  must  be  put  under  j 
control  and  strictest  supervision.  Fortunately,  in  fulfilling  this  task  i 
the  physician  meets  with  fewer  difficulties  than  in  other  mental  con-  : 
ditions,  owing  to  the  fact  that  the  paralytic,  treated  with  considera- 
tion and  tact,  is  easily  controlled.  It  is  a good  rule  not  to  delay 
sending  him  to  an  asylum,  and  this  applies  particularly  to  patients 
of  the  first  group.  Preference  is  to  be  shown  for  those  asylums 
which  have  large  grounds,  thus  enabling  patients  to  be  much  in  the 
open  air  and  to  be  occupied  in  rural  pursuits. 

In  addition  to  the  tranquillity  of  his  surroundings  and  the 
avoidance  of  those  emotions  to  which  business  life,  and  sometimes 
even  family  life,  expose  him,  it  is  advantageous  to  have  him  employed  | 
during  the  day  in  some  agreeable  occupation,  and  it  is  necessary  to  | 
give  him  good  nourishment,  eliminating  irom  his  diet  anything  that  , 
may  possibly  prove  too  stimulating.  | 

When  he  is  separated  from  his  family  and  removed  from  his  ; 
wonted  environment,  kindly,  authoritative,  and  intelligent  behaviour  j 
on  the  part  of  the  physician  almost  always  induces  in  the  mind  of  j 
the  paralytic  that  calm  which  is  vainly  sought  by  the  use  of  bromides  | 
and  other  common  depressants.  i 

We  have  now  to  take  up  the  question  whether  or  not  we  ought  | 
to  place  the  paralytic  under  mercurial  treatment.  Whatever  other  ; 
clinicians  may  think,  and  despite  the  vast  accumulation  of  the  results 
of  antisyphilitic  treatment,  I express  to-day,  after  a long  and  not 
happy  personal  experience,  with  frankness  equal  to  the  certainty 
with  which  I declare  it,  my  opinion  that  mercurial  treatment  does  not 
lend  itself  to  any  useful  result,  and  sometimes  even  is  dangerous. 

Not  one  of  the  patients  treated  carefully  with  hypodermic  , 
injections  of  sublimate  or  with  mercurial  inunctions  derived  any 
conspicuous  and  lasting  benefit  therefrom  ; many  of  them  who  had 
the  misfortune  to  fall  into  the  hands  of  unscrupulous  and  ignorant  | 
members  of  the  profession,  and  who  underwent  as  many  as  200,  and  | 
even  more,  hypodermic  mercurial  injections,  became  worse. 

The  improvement  of  the  few  was  slight  and  fleeting,  and  benefit 
could  not  be  attributed  to  the  mercury  any  more  than  to  the  suitable  'I 
and  favourable  conditions  in  which  the  patients  had  been  placed. 

Along  with  Professor  Penta,  I employed  intravenous  injections 
of  sublimate  (Baccelli’s  method)  in  those  cases  where  syphilis 
had  been  positively  demonstrated  ; but  I was  compelled  to  admit, 
from  the  rapid  aggravation  of  all  the  symptoms  of  the  disease,  that  it 
was  right  and  proper  to  discontinue. 

Paralytics  have  come  to  me  who,  after  having  been  in  the  hands 
of  syphilographers,  and  having  at  the  commencement  of  the  disease  ^ 
undergone  a long  course  of  mercurial  treatment  (100  and  more  ; 
injections  of  sublimate),  had  become  worse.  I am  of  opinion  that 


DEMENTIA  PARALYTICA 


831 


it  is  now  necessary  to  persuade  all  practitioners  that  mercurial 
treatment  is  more  often  hurtful  than  useful,  and  that  at  most  the 
clinician  free  from  preconceptions  may  employ  it  conscientiously  and 
prudently  within  judicious  limits,  suspending  it  by  degrees. 

During  the  past  year  I have  entrusted  to  Professor  Stanziale,  a 
well-known  and  esteemed  syphilographer  who  has  been  carrying  out 
inteiesting  researches  in  the  Naples  Asylum,  a large  number  of 
patients,  some  of  them  quite  recent,  for  rigorous  treatment  with 
injections  of  calomel.  No  conspicuous  advantage  has  followed. 

All  the  most  recent  data  of  recovery,  such  as  the  four  cases  of 
Leduc  and  the  six  of  Lemoine,  do  not  shatter  my  convictions  ; and 
the  results  of  the  intensive  method  above  recorded  dispelled  the 
enthusiasm  I derived  from  Leredde’s  book  (La  nature  syphilitique 
ei  la  curahilite  du  tabes  et  de  la  paralyse  generale,  1903). 

That  potassium  iodide  exerts  a modifying  action  on  the  inflam- 


matory process  or  on  the  arterial  sclerosis  remains  3/et  to  be  proved. 
In  several  cases  it  appeared  to  me  to  have  a certain  effect,  inasmuch 
as  I succeeded  in  obtaining  with  it  a significant  and  prolonged 
amelioration. 

Counter-irritants  to  the  head,  the  seton,  repeated  igneo-puncture 
of  the  neck  and  head,  antimonial  ointments,  iodine  applications 
(Pritchard,  Davies),  and  vesicants  have  proved  of  advantage.  I 
have  almost  always  employed  the  last,  as  they  are  well  tolerated, 
and,  being  easy  of  application,  are  very  useful  in  private  houses, 
whilst  the  antimonial  ointment  and  the  cautery  excite  paralytics, 
often  making  them  intolerant  and  irritable. 

Hydrotherapy,  in  the  form  of  the  douche,  is  almost  always  hurtful. 
I have,  however,  found  serviceable  baths  between  28°  and  32°  C., 
according  to  the  degree  of  excitement  of  the  patient,  along  with  a 
mild  cold  douche  to  the  head  ; but  I have  by  no  means  found  the 
enthusiasm  of  Voisin  justifled.  Moderate  applications  of  alternate 
heat  and  cold  on  the  abdomen,  foot-baths  in  congested  states  of 
the  head,  ice-bags,  or  the  frontal  douche  by  itself,  render  some 
modest  service  in  the  treatment. 

Ergot  is  the  least  deceptive  remedy  in  the  congestive  states 
that  are  almost  always  present  in  progressive  paralysis.  The  dose 
may  be  pushed  to  a few  grammes  of  ergotin  daily  for  two  or  three 
months,  without  causing  constipation  or  other  phenomena  of 
ergotism  (Girma).  It  may  be  substituted  by  injections  of  ergotin 
(Christian).  I have  preferred  the  liquid  extract  of  ergot  up  to 
40  drops  daily,  and  with  this  have  obtained  satisfactory  results  in 
the  habitual  congestive  states  and  the  apoplectiform  attacks  ; 
recently  I have  used  hypodermic  injections  of  stypticin. 

In  patients  with  pallid  features  and  failing  nutrition,  we  may 
add  the  use  of  quinine  and  tonics.  Strychnine,  phosphorus,  and 
especial^  the  strychnate  of  iron,  prove  hurtful. 

The  double  chloride  of  gold  and  sodium  has  been  lauded  bv  Bom- 


832 


PSYCHIATRY 


bila,  Hadies,  and  Costa,  in  doses  of  from  2 milligrammes  to  2 centi- 
grammes daily.  M.  Frise  and  Regis  have  derived  good  results  from 
suspension.  The  galvanic  current  has  rendered  no  small  service  in 
the  hands  of  others.  Jendrassick  has  used  with  great  advantage 
antifebrin  in  -|-gramme  doses  for  the  irritability  of  paralytics. 
Alarro  claims  good  results  from  the  use  of  potassium  cantharidinate, 
and  to  have  observed  true  recoveries  from  long-provoked  suppura- 
tions. 

Injections  of  sodium  glycero-phosphate,  cerebrin,  lecithin,  and 
disodic  methylarsenate  are  of  assistance  only  in  the  prodromal 
neurasthenic  stage. 

Trephining  has  been  proposed  by  Shaw,  and  has  been  practised 
also  by  B.  Tiike,  Wagner,  and  several  others.  This  operation  can 
have  no  other  effect  than  that  of  relieving  cerebral  compression  by 
draining  off  a part  of  the  fluid  collected  in  the  subarachnoid  spaces, 
and  in  the  perivascular  and  distended  lymphatic  channels — a not 
uncc-mmon  cause  of  the  epileptiform  and  paralytic  accessions.  Its 
effect,  however,  on  the  ulterior  course  of  the  malady  can  only  be 
transitory. 

The  episodes  of  acute  delirium  and  agitation,  the  numerous 
other  disquieting  and  threatening  symptoms,  such  as  insomnia, 
sitophobia,  retention  of  urine,  paresis  of  the  muscles  of  deglutition, 
bedsores,  and  visceral  diseases,  especially  pneumonia  and  the 
various  forms  of  catarrh  of  the  digestive  tract,  are  treated  in  para- 
lytics on  the  lines  indicated  by  general  and  special  therapeutics. 

A more  rational  attempt  has  recently  been  made  by  Robertson, 
who,  in  view  of  the  pathogenic  importance  of  the  Klebs-Loffier 
bacillus,  has  introduced  the  use  of  serotherapy  with  the  antidiph- 
theritic  serum  in  progressive  paralysis.  The  results  thus  far  obtained 
by  Robertson  are  not  very  encouraging.  If  we  could  prove  this 
bacillus  to  be  the  sole  toxic  agent  in  the  genesis  of  the  affection, 
there  is  no  doubt  the  use  of  antitoxin  would  have  good  results ; 
but  meanwhile  we  can  only  praise  the  rationality  of  the  attempt, 
which  should  be  imitated  and  encouraged. 


CHAPTER  XXXI 


LUETIC  DEMENTIA 

The  title  of  luetic  dementia  is  justified  by  the  fact  that  the  psychoses 
arising,  not  from  simple  intoxication,  but  from  the  syphilitic  pro- 
cess, always  present,  amongst  various  other  manifestations,  a 
deficit,  due  to  the  fact  that  wherever  there  is  a syphilitic  neoforma- 
tion there  is  a disturbance  or  alteration  of  the  nerve-elements,  so 
that  the  psychic  activity  of  the  sufferer  is  diminished,  either  generally 
or  partially. 

The  syphilitic  process  may  be  localized  in  a small  part  of  the 
cerebral  mantle,  or  it  may  extend  over  a larger  area  ; or,  again,  it 
may  be  restricted  to  the  vessels.  In  all  these  cases  the  range  and 
the  gravity  of  the  symptoms  depend  upon  th^  extent  and  depth  of 
the  seat  of  the  process.  The  syndromes,  therefore,  vary  to  an 
extreme  degree. 

Huebner,  and  many  German  authors  after  him,  have  distin- 
guished three  types  of  cerebral  syphilis. 

The  first  is  represented  by  epileptiform  attacks,  often  Jacksonian 
in  character,  by  incomplete  paralysis,  more  or  less  marked  psychic 
disturbances,  and  terminal  comatose  states.  The  second  variety 
is  characterized  by  apoplectic  or  apoplectiform  attacks,  consecu- 
tive hemiplegia,  psychic  disturbances  varying  in  degree  and  form, 
frequently  by  aphasia  in  one  or  other  form,  by  paralysis  of  the 
cranial  nerves,  and  often  by  attacks  of  somnolence.  The  third 
type  presents  phenomena  of  mental  decadence  and  somatic  facts 
which,  taken  as  a whole,  remind  us  of  paralytic  dementia. 

While  this  distinction  is  convenient  and  furnishes  points  of 
guidance  in  the  diagnosis,  it  must,  however,  be  agreed  that  luetic 
dementia  is  not  confined  within  the  limits  above  indicated.  The 
syndromes  vary  extremely,  as  might  be  expected  from  the  variations 
in  the  seat  and  extent  of  the  lesion.  From  simple  cephalalgia,  with 
li  progressive  mental  obtuseness,  due  to  cranial  periostitis  and  menin- 
gitis, up  to  hypochondriasis  and  sensory  insanity  resulting  from  a 
diffuse  gummatous  process,  as  in  the  case  reported,  there  is  a whole 
series  of  morbid  pictures,  varying  extremely  one  from  another, 

53 


834 


PSYCHIATRY 


although  they  can  all  be  recognised  from  specific  symptoms  and 
from  the  history  of  the  disease. 

Other  factors,  however,  intervene  and  complicate  still  more  the 
weft  of  facts,  thus  rendering  the  diagnosis  more  difficult.  If  around 
the  thrombotic  softening  produced  by  syphilitic  arteritis,  or  around 
the  haemorrhagic  focus  resulting  from  rupture  of  a degenerated 
artery,  non-specific  inflammatory  processes  be  developed,  and 
thereafter  secondary  degenerations,  the  relative  manifestations 
present  no  particular  features,  but  they  obscure  the  syphilitic 
syndrome.  Nevertheless,  the  result  of  treatment  will  make  the 
matter  clear,  for  all  these  complicating  factors  of  secondary  character 
obey  the  common  law  of  non-curability. 

With  regard  to  dementia  due  to  syphilitic  arterio-sclerosis,  the  j 
difficulties  are  increased  still  further,  because,  notwithstanding  the  j 
investigations  already  made  into  this  matter,  we  are  not  yet  in  a ! 
position  to  distinguish  syphilitic  arterio-sclerosis  from  the  arthritic  | 
and  alcoholic  variety.  The  difficulty  in  distinguishing  clearly  the  ' 
various  origins  of  the  arterio-sclerosis  has  induced  some  authors  to 
speak  of  a general  paralysis  that  is  syphilitic,  and  another  form  that 
is  non-syphilitic.  It  is  not  for  me  to  treat  this  subject  at  length 
here,  and  I say  only  that  neither  the  mode  of  onset,  the  sympto-  ; 
matic  complexus,  the  course,  nor  the  result  of  the  disease,  will  ' 
justify  such  a distinction. 

Fournier  distinguishes  six  initial  forms  of  cerebral  syphilis — the  1 
cephalalgic,  the  congestive,  the  epileptic,  the  aphasic,  the  mental,  ; 
and  the  paralytic.  j 

According  to  my  observations,  the  cephalalgic  variety  is  really  ! 
characteristic.  It  begins  with  pains  in  the  head,  which  gradually 
become  violent,  heavy,  or  acute,  at  first  localized  in  one  region  of;j 
the  cranium,  but  afterwards  extending  and  affecting  the  whole  of  j 
the  head.  The  pain  becomes  more  severe  towards  evening  and  i 
during  the  night  ; it  allows  no  rest,  deprives  the  patient  of  sleep,  | 
and  sometimes  causes  vomiting.  It  increases  with  pressure  on  the^ 
cranium  at  certain  points,  and  is  aggravated  by  percussion.  It  is. 
not  rare  to  find  a certain  oedematous  pastiness  of  the  scalp,  justf 
where  pressure  or  percussion  cannot  be  borne.  ! 

When  the  pain  becomes  worse,  sometimes  causing  the  patient !| 
to  cry  out,  a change  of  character  is  generally  noted  ; and  while  the 
affective  excitability  increases,  the  mental  force  diminishes,  so  that 
we  find  phenomena  of  real  mental  obtuseness.  There  is  slowness 
of  all  the  psychic  processes,  particularly  slowness  and  insufficiency 
of  memory.  There  are  terrifying  dreams  in  the  brief  intervals  of 
sleep,  and  generally  a condition  half  melancholic  and  half  stupid.; 
Sometimes  there  are  hallucinations  and  deliria. 

This  syndrome,  of  long  duration  if  the  diagnosis  be  not  made 
in  time,  and  if  treatment  is  resorted  to  only  at  a late  stage,  mayj 
finally  become  associated  with  factors  of  convulsion  and  paralysis.  | 


LUETIC  DEMENTIA 


835 


The  epileptic  or  Jacksonian  convulsions  and  the  paralysis  depend 
upon  the  cortical  or  basal  field,  where  the  syphilitic  process  is 
localized  or  is  most  intense. 

Notwithstanding  all  this,  it  appears  evident  that  the  distinction  of 
the  luetic  forms  as  made  by  Fournier  is  in  a certain  way  superfluous. 

It  should  be  remembered  that  the  luetic  encephalopathy  above 
described  becomes  paralytic  or  congestive  or  convulsive,  and  that 
each  of  these  forms  is  associated  with  very  distinct  symptoms 
belonging  to  the  other.  Fournier’s  distinction,  however,  has  some 
points  of  truth.  There  are  forms  of  cerebral  syphilis  that  do  not 
manifest  themselves  except  by  Jacksonian  epilepsy,  while  other 
forms  show  a richness  in  paralytic  phenomena  of  the  muscles  of 
the  eye,  intrinsic  or  extrinsic,  and  of  certain  cranial  nerves,  as  well 
as  of  the  limbs,  frequently  associated  one  with  another  in  such  a 
way  as  to  furnish  elements  for  diagnosis. 

Amongst  the  varieties  distinguished  by  Fournier,  one  that 
specially  calls  for  our  attention  is  the  paralytic  form,  for  the  eminent 
French  syphilographer  (and  many  others  along  with  him,  as  already 
noted)  distinguishes  a form  of  syphilitic  general  paralysis  from 
typical  and  genuine  paralysis.  He  desires  to  call  the  syphilitic 
paralysis  ‘ pseudo-paralysis,’  and  he  gives  distinctive  characteristics 
whereby  this  syphilitic  encephalopathy  can  be  distinguished  from 
true  progressive  paralysis.  Among  the  differential  symptoms 
should  be  noted  : 

1.  Absence  or  short  duration  of  the  delirium  of  grandeur.  Ac- 
cording to  some  authors,  like  Wille,  it  is  always  entirely  wanting. 

2.  Absence  or  transitory  presence  of  that  feeling  of  euphoria, 
strength,  and  well-being  that  is  so  frequent  in  typical  progressive 
paralysis. 

3.  Rarity  of  tremor,  particularly  in  the  tongue  and  lips. 

4.  Presence  of  ocular  paralysis,  and  sometimes  of  hemiplegia. 

5.  An  apoplectiform  commencement,  characterized  by  paralytic 
and  aphasic  attacks,  favours  pseudo-paralysis.  In  this  case  the 
mental  disturbances  are  secondary,  whilst  in  genuine  paralysis  the 
mental  disturbances  precede  the  somatic  disorders. 

The  opinions  expressed  by  Hermanides  {Les  affections  para- 
syphilitiques,  Haarlem,  1900)  are  almost  identical  with  the  above. 

Our  ideas  in  this  respect  are  well  known,  and  it  is  unnecessary 
to  repeat  them  here.  We  are  in  a position  to  put  observers  on  their 
guard  against  those  distinctions  that  have  not  a strong  basis  of 
observation.  True  syphilitic  encephalopathy  very  rarely,  or  perhaps 
never  at  all,  presents  the  same  clinical  picture  as  paralytic  dementia. 
When  this  appears,  whatever  be  the  nature  of  the  mDrbid  picture 
or  the  chronological  order  of  the  symptoms,  we  can  speak  only  of 
progressive  paralysis,  and  not  of  syphilitic  encephalopathy,  except 
in  relation  to  the  question  already  noted  as  to  the  syphilitic  genesis 
of  paralytic  dementia.  The  more  localized  forms  of  cerebral 

53—2 


836 


PSYCHIATRY 


f 

I. 

I 

syphilis  are  comparatively  frequent.  Goldflamm  pointed  out  : 
many  years  ago  that  the  most  frequent  cause  of  organic  diseases  | 
of  the  nervous  system  in  patients  between  twenty  and  forty  years  j 
of  age  is  syphilis.  Gazel,  Balzer,  Ferner,  Brasch,  Muriac,  and  | 
others,  are  of  the  same  opinion.  | 

The  symptoms  are  distinguished  as  transitory  and  permanent. 
The  former  are  very  frequent,  and  among  them  there  is  a pre\a- 
lence  of  ocular  paralysis  and  aphasic  attacks.  Among  the  latter 
are  to  be  noted  paralysis  of  the  limbs  and  mental  dehciencies. 
These  almost  always  exist  in  the  former  class  also,  and  vary  ex- 
tremely in  different  cases,  according  to  the  seat,  extent,  intensity, 
and  duration  of  the  process. 

Gajkiewicz  {Syphilis  du  systeme  nerveux,  1892)  affirms  that  ; 
affections  of  the  temporo-occipital  and  frontal  lobes  are  less  fre-  | 
quent  than  those  of  the  motor  zone,  and  to  the  lesions  of  the  frontal  | 
lobe  (gummata  and  specific  meningitis)  he  attributes  the  psychic  | 
deficiencies  observed  in  the  course  of  cerebral  syphilis— amnesia,  | 
want  of  attention,  indifference,  irritability,  affective  excitability,  | 
lack  of  energy,  and  susceptibility  to  suggestion.  | 

In  addition  to  these  manifestations  there  are  still  graver  s}ti-  | 
dromes,  veritable  acute  psychopathies,  such  as  attacks  of  mania  | 
or  of  confusion,  with  mental  decadence,  as  well  as  the  most  varied  | 
syndromes  due  to  destructive  foci.  I have  twice  obser\ed,  along 
with  cephalalgia  and  mental  obtuseness,  hemiplegia  in  association  1 
with  bilateral  hemianops'a  due  to  gummata  of  the  optic  thalamus  j 
and  of  the  posterior  part  of  the  capsule.  ;j 

According  to  some  other  authors,  syphilitic  pseudo-paralysis  1 
assumes  three  principal  forms,  referable  to  three  different  processes 
and  three  anatomical  regions  : '| 

1.  Meningeal  gumma.  I 

2.  Syphilitic  meningitis,  most  frequently  basal.  | 

3.  Syphilitic  arteritis,  with  thrombosis  and  consecutive  soften- , 

ings.  We  may  agree  to  accept  this  division  of  cerebral  syphilis  into  , 
three  forms,  but  to  give  to  the  syndromes  associated  therewith  thCf 
generic  appellation  of  pseudo-paralysis  is  to  cause  confusion  in  the 
pathological  and  clinical  pictures.  It  is  clear  that,  when  w’e 
endo-periarteritis  limited  to  some  branch  or  terminal  artery,  with  1 
consequent  thrombosis,  the  phenomena  wall  be  those  of  a cerebial  ^ 
malady  due  to  a focus.  On  the  other  hand,  wdien  the  arteritic 
process  is  diffuse,  and  there  follow’S  from  it  the  degeneration  of 
nervous  elements,  then  the  clinical  form  and  the  anatomo-palho- 
logical  substratum  are  those  of  ordinary  general  paralysis.  In! 
both  cases  there  is  a mental  deficit  (dementia),  but  there  is  a gieati 
difference  between  the  two  clinical  pictures.  | 

We  now'  come  to  the  epileptic  form  of  luetic  dementia.  ThiSj 
may  be  distinguished  from  ordinary  inherited  epilepsy  by  : | 

I.  Its  late  origin,  after  the  thirty-sixth  year  of  life.  | 


LUETIC  DEMENTIA  837 

2.  Its  commencement  in  Jacksonian  form,  and  its  subsequent 
complication  with  other  factors. 

3.  The  rapid  increase  in  the  number  of  hts,  very  soon  com- 
plicated with  paralysis,  aphasia,  and  mental  deficiency  (obnubila- 
tion of  the  mind). 

4.  The  evidence  of  grave  general  syphilitic  affection  (pallor, 
enlarged  glands). 

5.  The  efficacy  of  energetic  antisyphilitic  treatment. 

In  addition  to  this  form  of  direct  epilepsy,  Fournier  has  vigor- 
ously miintained  that  there  exists  a parasyphiiitic  and  a hereditary 
form  of  epilepsy  (inherited  syphilitic  epilepsy),  and  in  this  view  he 
has  been  supported  by  Brissaud  and  Kowalewski. 

This  variety  of  ep  lepsy  is  perhaps  in  no  way  different  from 
inherited  alcoholic  epilepsy. 

We  have  here  to  deal  with  an  intoxication  produced  by  the 
toxines  of  syphil's,  which  act  upon  the  nervous  tissues,  and  disturb 
not  only  the  general  nutritive  process  of  the  foetal  organism,  but 
particularly  that  of  the  nervous  system,  impeding  its  complete 
evolution.  It  is  possible,  however,  that  other  abnormal  products 
may  also  be  formed,  and  gain  an  entrance  to  the  blood  and  lymph- 
streams,  thus  leading  to  modihcation  of  the  chemical  constitution 
of  the  tissues,  and  alteration  of  the  nutritive  exchanges,  resulting 
in  dystrophies  of  the  nervous  elements  (cells  and  neuro-fibrils),  and 
perhaps  also  of  the  neuroglia. 

As  will  be  observed,  this  doctrine  is  only  a very  probable  hypo- 
thesis, and  has  not  been  demonstrated.  The  alterations  that  are 
found  at  the  autopsy,  alterations  of  the  nerve-cells  and  rarefaction 
of  the  myelinic  hbres,  especially  the  tangential  hbres,  may  well  be 
accounted  for  by  the  duration  of  the  disease.  The  same  remarks 
may  also  be  applied  to  syphilitic  hysteria.  Perhaps  the  grave  forms 
of  hysteria — ^hysterical  hemiplegia,  with  great  mental  torpor — ought 
to  suggest  to  us  the  possibility  of  syphilis. 

Kowalewski  {Allgcmeine  Zcitsch.  /.  Psych.,  1896)  holds  with 
Hermanides  and  others  that  syphilitic  hysteria  is  much  more  fre- 
quent than  is  generally  imagined,  and  that  in  hemiplegia  associated 
with  syphilitic  hysteria  the  disturbances  of  sensibility  are  less 
accentuated  (Achard),  giving  to  this  form  the  characteristics  of 
organic  hemiplegia. 

The  direct  primary  forms  of  epilepsy  and  of  hysteria  are  more 
amenable  to  the  influence  of  antisyphilitic  treatment,  whilst  the 
hereditary  forms,  within  certain  limits,  are  subject  only  to  sympto- 
matic treatment. 

For  the  pathological  anatomy  and  the  therapy  I must  refer 
readers  to  general  and  special  treatises  on  syphilis. 


CHAPTER  XXXII 

SENILE  DEMENTIA 

Insanity  does  not  spare  old  age.  All  the  psychopathic  forms  of 
the  second  group  find  their  representatives  to  a greater  or  less 
extent  in  advanced  age.  Most  frequent  of  all  are  mania  and  melan- 
cholia ; less  frequent  are  sensory,  alcoholic,  and  luetic  insanity. 

I have  occasionally  seen  an  aged  morphinist  and  a patient  who  has 
become  paranoic  when  advanced  in  years. 

Epilepsy  is  not  an  uncommon  accompaniment  of  old  age,  and 
is  due  to  atheroma. 

The  progressive  paralyses  of  the  aged  and  the  psychic  altera-  . 
tions  consequent  upon  destructive  foci  are  treated  in  the  respective  . 
chapters,  and  are,  in  my  opinion,  to  be  excluded  from  the  study  of  ; 
true  senile  dementia.  ! 

The  psychoses  mentioned  do  not  assume  special  forms  in  old 
age  ; their  clinical  figure  is  preserved  unaltered  in  its  fundamental  ^ 
lines,  except  for  some  special  character  given  to  it  by  peculiarities 
of  the  mind  of  the  aged  person.  These  cases  may  end  in  recovery. 

It  is  a matter  of  common  knowledge  that  in  old  age  the  psychic  ■ 
processes  are  slower.  Whether  that  be  due  to  some  obstacle  in  the  ’ 
transmission  over  the  old  and  exhausted  paths,  or  to  the  great  j 
increase  in  the  number  of  psychic  components  accumulated  in  the  | 
memory  in  the  course  of  a long  experience,  thus  giving  rise  to 
greater  difficulty  in  selection,  and  demanding  more  time  for  dis- 
crimination ; or,  again,  whether  it  be  due  to  the  slowing  down  of 
operations  in  the  exhausted  laboratories  of  thought  in  aged  persons, 
a certain  torpor  can  be  noted  in  all  the  manifestations  of  psychic 
life,  a tendency  to  repose,  a certain  Mck  of  interest  in  all  those 
matters  that  do  not  immediately  concern  the  subject. 

An  air  of  melancholy  invests  the  mind  of  the  aged  man,  as  he 
becomes  conscious  of  the  shortness  of  the  time  that  remains  to  him 
in  comparison  with  the  period  he  has  already  lived. 

The  world  of  his  youthful  dreams  and  the  aspirations  of  his 
adult  age  now  suffers  a constant  diminution  in  his  mind,  whilst 
the  world  of  experience  and  of  reality  stands  before  him  and  op- 

838 


seniLe  dementia 


839 


presses  his  consciousness  as  with  fear.  The  failing  of  his  muscular 
strength,  and  above  all  the  passing  of  the  sexual  life,  fill  the  mind 
with  an  ill-dissimulated  sadness,  the  only  compensation  being  the 
experience  of  obstacles  that  have  been  overcome  and  the  authority 
that  attends  such  experience,  and  which  the  subject  feels  to  the 
full.  With  mind  less  inclined  to  the  pleasures  of  existence  in  pro- 
portion to  the  diminished  vigour,  he  feels  external  stimuli  less 
intensely  than  he  did  in  the  past,  and  becomes  a pessimist  in  his 
judgment  of  present  and  modern  matters,  whilst  the  lively  recol- 
lection of  the  days  of  joyful  youth  causes  the  subject  to  become  a 
laudator  temporis  acti. 

His  defective  energy  makes  him  suspicious  of  the  young,  who 
press  on,  with  their  intense  and  abundant  aspirations,  to  take  his 
place,  and  so  he  becomes  more  circumspect  and  more  austere, 
clinging  all  the  more  closely  to  everything  that  belongs  to  him,  to 
that  portion  of  the  ego  that  we  have  termed  ‘ mine,’  the  symbol 
of  force  and  victory  in  the  past,  and  the  title  that  gives  him  the 
right  to  esteem  and  affection,  and  the  dignity  of  a master.  His 
possessions,  his  ‘ mine,’  make  up  for  the  failing  and  passing  ego. 

The  memory  is  weakened  ; recollection  of  recent  names  and 
facts  is  colourless  and  fugitive.  Things  are  represented  as  vague 
shadows  which  the  decaying  old  man  cannot  grasp.  The  power 
of  evocation  and  of  reproduction  remains  to  the  extent  that  the 
old  man  can  evoke  a great  number  of  recollections,  particularly 
of  long-past  events.  The  fact  is  that  with  him  rpcent  images  are 
not  formed  in  such  a way  as  to  be  capable  of  easy  re-evocation  and 
reproduction.  As  Mercier  well  puts  it,  the  defect  lies  in  the  ‘ forma- 
i tion  of  structural  memories.’  In  this  way  the  old  man  lives  among 
■ images  and  recollections  of  the  past.  These  are  represented  with 
fidelity  and  vivacity,  and  not  interfered  with  by  the  colourless 
images  of  recent  formation,  so  that  it  may  readily  be  understood 
' how  he  keeps  before  his  mind  mainly  the  events  ‘ of  his  past.’ 

Such  a defect  in  recent  mental  representations  in  the  mind  of 
the  aged  subject  undergoing  involution,  is  the  cause  of  certain  par- 
ticular attitudes  of  mind,  and  even  of  real  errors.  If  an  old  man  of 
seventy  marries  a young  woman  of  twenty,  the  reason  is  that  he, 
although  apparently  sane,  has  a particular  consciousness  in  whose 
field  of  vision  predominate  juvenile  images  and  recollections  that 
give  him  the  illusion  of  power,  although  his  actual  power  is  abso- 
lutely inferior  to  the  most  elementary  requirements  of  his  new 
position.  Two  figures  with  opposite  tendencies  appear  in  these 
marriages,  which  are  condemned  alike  by  psychology  and  by  morality. 
The  young  woman,  knowing  well  what  she  does,  marries  the  ‘ pos- 
S sessions  ’ of  the  old  man,  and  dreams  of  happiness  with  riches  ; 
whilst  the  old  man,  losing  his  contact  with  reality,  declines  more 
rapidly  than  before,  relaxing  his  hold  over  his  ‘ own.’ 

Another  psychic  feature  frequent  in  senile  mental  decadence  is 


840 


PSYCHIATRY 


suspicion,  and  it  is  particularly  marked  in  those  who  have  accumu- 
lated a more  or  less  considerable  fortune,  but  have  no  direct  heirs. 
In  these  cases  the  internal  ego  is  attached  more  closely  to  the 
object  possessed,  as  though  from  it  there  emanates  a compensating 
force  hat  gives  animation  and  causes  in  the  subject,  as  he  regards 
the  products  of  his  activity,  the  illusion  that  he  still  possesses  his 
old  energy. 

This  psychological  phenomenon  becomes  associated  with  another 
— viz.,  the  suspicion  that  other  persons  are  trying  to  deprive  him 
of  his  ‘ possessions,’  or  that  they  look  upon  them  with  covetous 
eyes.  This  is  the  origin  of  the  excessive  care  that  he  takes  to  hide 
his  treasures,  great  or  small.  In  the  gravest  cases  he  sometimes 
forgets  the  hiding-place,  and  breaks  into  mania,  believing  that  he 
has  been  the  victim  of  theft.  Old  men  of  this  sort,  whose  powers 
have  greatly  decayed,  become  exacting,  thankless,  diffident,  insen- 
sible, and  egoistic.  They  insist  rigidly  on  the  hours  for  meals  and 
for  going  to  bed,  and  they  do  not  share  in  any  of  the  cares  of  their 
families.  Even  though  the  logical  processes  may  appear  to  be,  or 
may  really  be,  unaffected,  we  have  in  such  conduct  the  proof  of 
mental  involution. 

Such  subjects  are  often  extremely  emotional  and  irritable. 

The  organic  functions  assume  a preponderating  place  in  the 
tonality  of  senile  life.  Many  old  persons  are  preoccupied  with  the 
intestinal  functions,  and  any  retardation  of  these  becomes  for  them 
a question  of  the  highest  interest.  This  extreme  care  that  they 
take  of  their  health  assists,  in  neurasthenic  and  melancholic  states 
of  old  age,  in  the  formation  of  hypochondriacal  deliria,  which  at 
such  an  age  very  often  reach  the  maximum  point  of  deliria  of 
negation. 

Such  a totality  of  facts  is  found  only  in  a few  aged  subjects,  and 
the  phenomena  appear  at  very  different  ages.  There  are  old  men  of 
sound  mind  who  retain  the  fulness  of  their  mental  vigour  until  their 
last  days,  and  there  are  men  who  become  psychically  old  almost  as 
soon  as  they  reach  maturity.  The  age  of  many  is  the  age  of  their 
vessels,  the  degeneration  of  which  is  for  the  most  part  an  index  of 
senility.  History  is  full  of  examples  of  old  men  who  were  mentally 
vigorous,  just  as  our  experience  is  full  of  men  precociously  aged. 
There  is  a wide  intermediate  zone,  with  all  shades  of  morbidity. 

When  the  above-mentioned  psychic  stigmata  are  present,  but 
not  highly  accentuated,  they  impress  their  own  particular  character 
on  the  malady  that  supervenes  ; but  still  in  such  a case  we  cannot 
speak  of  true  senile  dementia  : psychoses  bearing  the  characteristics 
of  senility  may  still  be  cured. 

One  variety  appears  to  me  to  be  very  frequent  and  obstinate — ■ 
namely,  the  anxious  melancholia  of  those  aged  subjects  who  have 
enjo\’ed  life  much,  or  who  have  been  much  attached  to  mundane 
pleasures.  The  passing  of  their  maturity  plunges  them  into  a state 


SEN17.E  DEMENTIA 


841 


of  anguish  during  which  they  continually  lament  their  endless 
sufferings,  overmastered  by  a tormenting  fear  that  they  will  not 
recover. 

They  have  themselves  frequently  examined  by  doctors ; they 
constantly  repeat  the  same  phrases,  and  are  always  talking  of  their 
sufferings  and  their  anguish.  The  mental  decay  is  slow,  and  shows 
itself  hrst  in  the  field  of  the  affections.  Such  persons  become 
extremely  selfish,  pretentious  and  overbearing  in  their  families, 
whom  they  keep  constantly  busied  with  their  sufferings.  They 
become  humble,  childish,  or  even  servile  towards  their  medical 
advisers,  from  whom  they  still  hope  for  remedies  that  will  enable 
them  to  return  to  their  old  pleasures,  the  story  of  which  has  filled 
the  greater  part  of  their  lives.  The  power  of  attention  and  memory 
gradually  decay,  until  the  stigmata  of  senile  dementia  become  very 
apparent.  Arterio-sclerosis,  atheroma,  and  granular  kidney  are 
usually  present. 

Sometimes  true  senile  dementia  is  preceded  by  an  acute  hallu- 
cinatory phase,  at  other  times  by  facts  which,  for  a longer  or  shorter 
period,  give  a false  appearance  of  neurasthenia,  and  more  rarely  of 
one  or  other  of  the  forms  of  melancholia  or  of  mania.  In  most 
instances,  however,  the  dementia  is  primary,  and  advances  in- 
sidiously and  slowly.  In  any  case  we  always  find  defects  of  judgment 
and  of  memory,  childish  conduct,  and  general  discontent,  frequently 
rendering  these  patients  querulous  and  petulant. 

The  varieties  of  sen  le  dementia  may  be  classed  in  two  groups 
those  of  erethistic  and  those  of  apathetic  form.  In  the  erethistic 
form  there  is  great  exaggeration  of  the  emotivity,  and  hence  it  is  why 
such  patients  are  intolerant  of  impressions  and  of  contradictions. 
They  are  extremely  sensitive  and  irritable,  and  the  more  so  because, 
owing  to  their  great  liability  to  forget  things  and  to  commit  errors  of 
judgment,  they  are  deficient  in  the  ordinary  circumstances  of  family 
life.  Such  affective  irritability  is  kept  alive  also  by  their  sufferings — 
cephalalgia,  vertigo,  weariness,  paraesthesia,  and  other  subjective 
disorders.  The  nights  are  passed  in  sleeplessness,  and  oneiric 
states  are  frequent.  The  subjects  are  restless,  and  get  out  of  bed. 
They  wander  about  the  house  in  a dazed  condition  ; they  cannot 
tell  what  they  want,  and  they  are  quite  out  of  their  reckonings. 
They  show  great  changeability  of  humour,  sometimes  even  daily 
fits  of  confusion,  and  they  suffer  from  hallucinatory  episodes,  with 
more  or  less  marked  agitation. 

The  apathetic  form  is  characterized  by  a slow  and  progressive 
mental  decadence,  in  which,  besides  the  usual  phenomena  of  amnesia 
and  dysmnesia,  there  prevails  a marked  indifference  to  everything 
and  everybody.  This  picture  corresponds  with  what  is  also  normally 
found  in  certain  old  men,  who  behold  with  indifference  the  ruin  of 
their  households  and  the  destruction  of  their  families. 

Patients  belonging  to  this  group  enjoy  good  health,  and  are  as 


842 


PSYCHIATRY 


calm  as  they  are  vacant.  They  make  no  lamentations,  and  fre- 
quently are  as  satisfied  and  contented  as  the  gods  of  Olympus. 

A well-preserved  and  smiling  old  woman  of  seventy-eight,  who 
remembers  nothing,  occupies  herself  with  nothing,  does  no  work,  and 
is  affected  by  nothing,  will,  if  an  opportunity  arises  during  conversa- 
tion, tell  you  that  she  would  be  very  pleased  to  marry  if  she  could 
find  a husband,  because  she  is  well  fitted  to  undertake  the  manage- 
ment of  a house.  Another  will  talk  for  a long  time,  mixing  up 
places,  persons,  dates,  events,  speaking  of  people  who  have  been 
long  dead  as  still  living,  though  she  was  much  afflicted  by  their 
deaths,  etc.  As  a rule,  the  most  impressive  episodes  of  their  lives  1 
are  mistaken  for  recent  events,  occurring,  as  it  were,  to-day,  and  i 


Fig.  ioo. — A Cell  from  the  Anterior  Rolandic  Convolution  (Ocular,  8 ; ; 

Objective,  yV  Immersion,  K).  • 

The  endocellular  reticular  apparatus  is  sufficiently  well  preserved.  At  some  parts  ] 
of  the  cell  the  anastomosis  of  the  fibrillae  is  evidenC  { 

they  rehearse  the  scenes,  to  a certain  extent,  with  imaginary  persons,  j 
making  them  occupy  places  other  than  those  in  which  they  actually 
occurred. 

Again,  patients  belonging  to  this  second  group  generally  give 
much  trouble  to  their  families  or  to  the  asylum  attendants  during 
the  night,  for  they  have  no  idea  where  they  are  ; and  if  they  meet 
with  opposition,  the}^  cause  a great  uproar,  scratching,  yelling,  and 
rushing  about. 

In  both  groups  we  may  observe  the  disappearance  of  the  higher 
mental  powers  in  the  inverse  order  of  their  appearance.  The  powers 
last  developed  are  the  first  to  disappear,  and  so  on,  until  their  whole 
life  is  circumscribed  to  the  instinct  of  self-preservation. 


SENILE  DEMENTIA 


843 


When  the  malady  proceeds  slowly,  the  mental  decay,  if  not  far 
advanced,  is  concealed  for  a long  time  by  gentlemanly  or  ladylike 
behaviour  belonging  to  a remote  past,  the  conduct  thus  followed 
and  certain  habits  still  retained  forming  a psychological  automatism 
(the  habit  of  reading  and  of  meditating,  and  certain  gentlemanly  or 
ladylike  attitudes,  etc.)- 

The  physical  health  of  some  of  these  demented  subjects  is  well 
preserved  for  a long  time,  all  their  functions  go  on  regularly,  and  they 
themselves  feel  quite  well.  It  is  only  when  the  dementia  has  made 
great  progress  that  the  organic  weakness  becomes  pronounced, 
showing  itself  in  disturbances  of  digestion,  bronchial  troubles,  renal 
mischief,  attacks  of  congestion,  and  marasmus. 

The  somatic  phenomena  are  not  of  much  significance.  Those 
described  by  some  writers  in  the  syndromes  of  the  senile  psychoses 
and  of  senile  dementia  belong  to  other  clinical  pictures.  I do  not 
speak  of  the  somatic  characteristics  of  senility,  such  as  gray  hairs, 
furrows,  and  the  arcus  senilis.  None  of  the  phenomena  of  paralytic 
or  of  post-apoplectic  dementia  are  found  in  genuine  senile  dementia, 
except,  in  a few  cases,  senile  tremor,  very  like  Parkinson’s  tremor, 
extending  to  the  lips  and  the  lower  jaw.  Paralyses  of  the  most 
varied  nature,  hemiopia,  and  sensory  disturbances,  form  part  of  the 
clinical  picture  of  post-apoplectic  dementia.  Dysphasic  disturb- 
ances reveal  the  presence  of  foci  in  determinate  parts  of  the  brain, 
and  we  have  decisively  separated  the  clinical  manifestations  of  these 
from  the  clinical  picture  of  senile  dementia. 

I have  never  found  abolition  of  the  tendinous  reflex,  nor  dys- 
arthria in  senile  dementia.  The  presence  of  either  of  these  two 
phenomena,  especially  dysarthria,  is  a sign  of  progressive  paralysis, 
which  sometimes  is  developed  at  a late  stage  in  the  lives  of  old 
people. 

One  of  the  somatic  phenomena  sometimes  episodically  met  with 
is  catalepsy.  Here  we  have  to  deal  with  attacks  of  catalepsy 
coinciding  with  states  of  stupor  (Brissaud  and  Lamy,  Dupre  and 
Rabe,  Bauer).  As  in  acute  dementia  and  hysteria,  this  phenomenon 
is  associated  with  paralysis  or  with  inhibition  of  the  regulative 
powers.  There  is  nothing  particular  to  be  noted  after  we  have  once 
brought  this  phenomenon  into  relation  with  the  suppression  of  the 
higher  cerebral  powers,  as  in  cases  of  confusion,  somnambulism,  etc. 

Again,  I have  long  observed  a form  of  spastic  paraparesis,  well 
described  by  Pic  of  Lyons.  After  the  investigations  of  Reverchon 
{La  Paresie  spasmodique  des  Atheromateux,  1902),  this  can  now  be 
attributed  to  lacunar  foci  of  cerebral  disintegration  resulting  from 
atheromatous  degeneration  of  the  cerebral  arteries. 

In  addition  to  the  acute  psychoses  to  which  the  aged  may,  like 
other  people,  become  subject,  and  which  bear  certain  features  attri- 
butable to  the  psychic  orientation  of  the  aged  person,  the  senile 
dement,  irrespective  of  degree  of  retrogression,  may  suffer  from 


844 


PSYCHIATRY 


acute  vesanic  attacks  of  confusion,  with  hallucinations  and  psycho-; 
motor  agitation.  j 

It  not  infrequently  happens  that  a demented  subject  can  give  a| 
fair  account  of  himself  at  a first  interview,  for  even  though  certain  | 
very  distinct  signs  of  his  malady  may  appear,  his  answers  are  not 
without  a certain  order  and  a certain  degree  of  knowledge  ; but  after 
a few  days  he  may  be  found  to  be  extremely  confused,  dazed,  and  j 
incapable  of  giving  his  thoughts  any  precise  direction.  On  close  i 


Fig  ioi. — Cell  from  the  Anterior  Rolandic  Convolution  (Ocular,  8^ 
Objective,  yV  Immersion,  K).  • 

The  fibrillae  are'visible  in  some  prolongations  from  which  they  extend  to  the  peri? 
nuclear  zone.  They  are  absent  from  the  remainder  of  the  protoplasm.  ' 


examination,  we  perceive  an  acetonic  odour  in  the  breath,  and  may; 
find  serious  intestinal  disorders  ; or,  again,  the  lenal  functions  may| 
be  very  much  reduced,  and  albumin  and  tube-casts  present  in  the 
urine.  Here  we  have  the  superaddition  of  infection  or  intoxication! 
— a fact  that  has  been  brought  out  clearly  by  Ritti  and  by  Regis.  | 
Given  the  psychic  deficiency  of  morbid  senility,  the  most  diversej 
forms  of  morbid  conduct  and  of  delirium  are  possible.  Here,  too,! 
the  pre-existing  mental  content  and  the  moral  orientation  of  each! 
individual  assume  the  highest  importance.  | 


SENILE  DEMENTIA 


845 


Fig.  102. — Cell  from  the  Second  Frontal  Convolution  (Ocular,  8j 
Objective,  yV  ; Immersion,  K). 

The  endocellular  apparatus  is  destroyed.  In  the  body  of  the  cell  numerous  globules 
of  the  so-called  yellow  globular  degeneration  may  be  observed. 


i 

Fig.  103. — Cell  from  the  Second  Occipital  Convolution  (Ocular,  8 ; 
Objective,  ; Immersion,  K). 

In  a great  part  of  the  cell  the  fibrillae  are  not  visible.  One  bundle  can  be  observed 
(but  even  it  does  not  present  a normal  aspect)  passing  from  the  apical  into  a 
basal  prolongation. 


846 


PSYCHIATRY 


For  example,  an  old  woman  whose  consciousness  is  filled  with 
erotic  aspirations  and  emotions  will  assume  a coquettish  air  that  is  I 
childish  and  i idiculous.  A man  of  seventy-eight,  hearing  some  words  | 
spoken  jestingly  by  a young  friend  of  the  family,  begins  to  suspect  | 
that  the  latter  is  intriguing  with  his  wife,  a woman  of  seventy -five. 
Shortly  thereafter  a real  delirium  of  jealousy  is  organized,  and  some 
fine  day  he  will  waylay  that  friend  of  the  family,  and  shoot  him  with  ' 
a revolver.  Such  a case  I have  myself  observed.  In  all  these  sub- 
jects there  is  a great  defect  of  perception  and  of  critical  power  ; and 
mental  poverty,  in  every  form  and  direction,  appears  clearly  and 
incontestably  to  be  the  dominating  note  of  all  the  mental  manifesta- 
tions. 


Pathological  Anatomy. — Senile  dementia  has  a dystrophic  sub- 1 
stratum.  In  one  category  of  cases  there  is  a prevalence  of  ' 
atheromatous,  vascular  degeneration,  associated  with  marked  | 
neuroglial  proliferation  ; while  in  another  group  the  nerve-cells  are  i 
involved  in  a true  involutionary  atrophic  process,  with  various  forms  i 
of  degeneration,  particularly  the  form  characterized  by  pigmentary  | 
infiltration,  already  well  described  by  Pierret  and  Troisier,  by  i 
Marinesco  {Revue  scientifique,  1900),  and  by  Bridier  {These  de  Lyon,  | 
1902).  The  yellow  degeneration  described  by  Colucci  is  also  fre-  : 
quent.  With  Ramon  y Cajal’s  method,  as  applied  by  Fragnito,  we 
can  see  that  the  fibrillar  structure  of  the  cell  protoplasm  is  gravely 
affected.  ^ 

In  a case  of  advanced  senile  dementia  the  destruction  of  the  ;| 
neuro-fibrillae  appears,  as  shown  in  Figs.  100  to  104,  to  be  much  more 
extensive  than  in  the  brain  of  a paralytic  subject.  t| 

The  lesions  of  the  nervous  and  protoplasmic  prolongations  are  i 
very  similar  to  the  alterations  met  with  in  paralytic  dementia  ; here  | 
also  many  nerve-fibres  are  found  to  be  atrophied  and  degenerate.  / 
The  neuroglia  is  everywhere  more  or  less  increased,  but  not  to  a very  . 
high  degree.  Foci  of  atrophic  softening  are  frequent,  especially  in  ; 
the  white  matter  immediately  below  the  cortex.  These  are  generally  • 
extremely  small,  and  are  sometimes  surrounded  by  sclerotic  tissue, 


Prognosis. — The  prognosis  of  senile  insanity  is  not  absolutely 
grave. 

Many  cases,  irrespective  of  form,  end  in  recovery.  Sometimes, 
however,  the  prognosis  presents  insuperable  difficulties,  because 
dysorientation  is  very  apt  to  occur  in  an  aged  subject,  and  there 
are  often  phases  of  confusion,  which  sometimes  resemble  states  of 
grave  dementia,  although  they  alternate  with  states  of  surprising 
lucidity.  Such  a succession  of  phases  of  confusion  is  related  to 
the  readier  disturbances  of  the  circulation  and  the  lessened  resist- 
ance offered  by  the  nerve-cells  that  have  already  undergone  involu- 
tion. 


SENILE  DEMENTIA 


847 


It  is  different  with  cases  of  confirmed  dementia,  for  there  the 
prognosis  is  always  hopeless.  Senile  dementia  is  slowly  progres- 
sive. 

Therapy. — The  treatment  consists  solely  in  maintaining  all  the 

I 

i 


Fig.  104. — Cell  from  the  Anterior  Rolandic  Convolution  (Ocular,  8 ; 
Objective,  ; Immersion,  K),  showing  many  Globules  of  Yellow 
Globular  Degeneration  and  some  Broken  Fibrill^  in  the  Body  of 
THE  Cell  and  in  the  Prolongations. 


organic  functions  in  regular  operation,  especially  those  of  the  heart 
and  the  abdominal  organs. 

Special  symptoms,  such  as  insomnia,  agitation,  and  anguish, 
must  be  treated  on  general  lines. 


CHAPTER  XXXIII 


POST-APOPLECTIC  DEMENTIA 

Were  I to  try  to  describe  all  the  psychic  disturbances  associated  : 
with  hemiplegia  and  with  destructive  foci  in  general,  and  all  the  ; 
circumstances  preceding,  accompanying,  or  following  the  formation  | 
of  cerebral  foci,  I should  very  much  exceed  the  limits  that  I have  | 
thought  well  to  lay  down  for  this  study.  There  is  really  no  neces-  I 
sity  to  take  into  consideration  all  those  mental  affections  in  which  j 
the  hsemorrhagic  or  thrombotic  focus  is  simply  an  episode,  how-  ; 
ever  frequent  it  may  be,  as  in  the  case  of  epilepsy,  progressive  ; 
paralysis,  consecutive  dementia,  and  other  psychopathies.  On  the  | 
contrary,  I must  limit  myself  to  the  description  of  psychic  disturb-  ‘ 
ances  belonging  to  the  cerebral  attack,  and  those  that  are  the 
mediate  or  immediate  consequence  of  the  cerebral  lesion  itself.  ^ i 
Two  classes  of  psychic  disturbances  must,  therefore,  be  studied 
—the  concomitant  and  the  consecutive.  ^ 

The  first  are  those  that  accompany  the  apoplectic  attack  in  .j 
the  symptomatic  complexus  of  which  paralysis  is  frequently  a | 
predominant  symptom,  and  they  are  reduced  to  the  states  of  con-  , 
sciousness  during  coma  or  subcomatose  conditions  ; or,  again,  to  , 
progressive  restriction  of  the  intellectual  field,  due  to  multiple  foci, . 
or  to  compression  of  the  brain.  The  others  follow  the  cerebral , 
lesion,  after  the  disappearance  of  all  the  acute  phenomena  of  thei 

cerebral  attack.  i 

The  comatose  state  may  be  established  suddenly  or  gradually. ; 
It  may  be  most  profound  at  the  very  commencement,  and  gradually 
disappear,  ending  in  simple  somnolence  and  the  complete  return 
of  consciousness  ; or,  on  the  other  hand,  it  may  begin  \\  ith  \ ertigo, 
confusion,  dysorientation,  simple  obnubilation  of  the  sensorium, 
and  may  more  or  less  rapidly  reach  the  grade  of  profound  coma. 
In  any  case  a characteristic  feature  of  the  trouble  is  its  appear- 
ance when  the  patient  is  in  the  most  satisfactoiy  state  of  health, 
or  is  disturbed  only  by  slight  or  insignificant  premonitory  symp- 
toms. 

In  the  latter  case,  even  though  there  are  grave  premonitoiyi 

848 


POST-APOPLECTIC  DEMENTIA 


849 


symptoms,  such  as  recurring  cephalalgia,  vertigo,  fumes  and  sense 
of  fulness  in  the  head,  stunning  sensation,  and  changes  of  humour, 
as  a rule  no  great  importance  is  attached  to  them  by  the  sufferers 
before  they  fall  victims  to  the  attack  of  apoplexy.  On  the  other 
hand,  in  the  case  of  lesions  of  slow  development,  such  as  the  neo- 
plasm^., or  certain  cases  of  cerebral  thrombosis,  there  is  usually 
observed  a slow  and  progressive  restriction  of  the  mental  field, 
with  continuous  weakening  of  the  memory,  greater  or  less  psychic 
depression,  great  slowness  in  the  processes  of  perception  and  reac- 
tion, somnolence  and  irritability,  with  diminished  self-control. 
This  state  may  go  so  far  as  abolition  of  all  psychic  activity  in  a 
deep  sleep,  which  may  be  prolonged  for  days  or  weeks,  until  finally 
an  apoplectic  attack  or  state  of  epilepsy  closes  the  scene.  The 
subsequent  psychic  disturbances  are  most  various,  and  require  a 
still  more  detailed  analysis.  It  is  not  always  easy  to  interpret 
them,  especially  those  caused  by  extremely  circumscribed  destruc- 
tive foci.  The  intellectual  faculties  are  not  localized  exclusively  in 
any  one  part  of  the  brain,  for  all  the  various  provinces  of  which  the 
brain  is  composed  contribute  in  different  degrees  and  in  various 
ways  to  the  constitution  of  the  psychic  organism,  and  to  the  ex- 
plication of  the  activities  of  the  mind.  In  the  same  way  as  a 
stroke  of  the  brush  or  a touch  of  colour,  either  of  them  of  no  value 
in  itself,  may  acquire  great  aesthetic  value  in  the  harmony  of  a 
painting,  so  contributions  to  mental  efficacy  and  harmony  may 
be  made  by  the  products  of  regions  of  the  brain  that  apparently 
possess  no  real  importance  in  the  machinei*}^  of  the  psychic  activities. 

The  fact,  now  almost  generally  accepted,  that  the  brain  is  com- 
posed of  units,  which  all  concur  with  a coefficient  of  useful  product 
of  their  own  work,  and  of  associative  paths  establishing  communica- 
tion between  the  divers  units,  or  groups  of  units,  adjacent  or  widely 
separated,  through  which  alone  the  associated  work  and  the  com- 
plex product  become  possible,  leads  us  to  admit  without  discussion 
that  any  destructive  focus  whatsoever  in  the  brain  must  have  as 
an  effect  a diminution  of  the  mental  patrimony  and  the  vigour  of 
the  personality  in  some  direction  or  other. 

This  general  fact  is  subject  to  few  exceptions.  The  person  who 
has  a destructive  focus  in  his  brain  must,  psychically  considered, 
be  in  some  degree  different  from  what  he  was  prior  to  the  attack  of 
which  hemiplegia  is  the  sign,  and  in  most  cases  the  ineradicable 
sign.  Men  who  were  formerly  active  labourers,  eager  in  the  pursuit 
of  their  affairs  and  the  care  of  their  families,  become  in  various 
degrees  indifferent,  apathetic,  or  indolent  ; and  as  though  the 
source  of  their  activities  had  dried  up,  the  majority,  if  not  all,  of 
them  are  no  longer  in  a position  to  form  any  proposition,  or  to 
translate  it  into  action,  when  it  requires  a certain  degree  of  energy 
or  a special  exercise  of  moral  force.  The  fountains  of  imagination 
are  exhausted,  and  the  man  who  was  noted  for  his  bold  proceedings 

54 


850 


PSYCHIATRY 


becomes  indifferent  or  timid  and  undecided  in  the  affairs  of  his  | 
everyday  life  and  in  matters  relating  to  his  own  needs  and  those 
of  his  family  ; or  he  becomes  negligent  of  public  concerns,  to  which 
he  formerly  devoted  himself  unceasingly  and  with  great  efficiency. 
Sometimes  the  ideative  process  is  not  at  all  inactive,  but  it  does 
not  attain  the  former  degree  of  tonality  and  vivacity  requisite  for 
translation  of  the  idea  into  action.  Power  of  observation  is  fre- 
quently defective.  Everything  wears  more  fading  and  more  evan-  | 
escent  colours.  The  memory  is  obscure  and  unreliable,  this  defect  ; 
applying  to  words  more  than  to  events — and,  among  words,  to  i 
nouns  more  than  verbs  ; among  events,  to  recent  happenings 
rather  than  the  more  remote.  Speech  becomes  less  vivacious,  | 
colourless,  and  halting,  and  it  is  difficult  to  maintain  a long  con-  | 
versation.  Weariness  soon  overtakes  the  speaker,  and  sometimes  j 
he  falls  asleep  whilst  actually  speaking.  I 

I myself  have  known  politicians  who,  from  their  knowledge,  | 
their  Parliamentary  activity,  their  rapidity  of  conception  and  facility 
of  speech,  had  acquired  a leading  position  amongst  the  politicians 
of  the  country;  yet,  after  an  attack  of  apoplexy,  although  they 
were  apparently  unharmed,  and  kept  their  seats  in  Parliament, 
they  were  silent  members,  or  at  the  utmost  they  attempted  some  1 
lobby  intrigue,  in  which  they  were  unsuccessful.  i 

Such  patients  are  tormented  by  cephalalgia,  accompanied  by  | 
a sense  of  weight,  and  often  by  vertigo  ; sometimes  they  are  over-  ; 
whelmed  by  a feeling  of  anguish  and  of  oppression,  as  though  their  j 
end  were  near,  so  that  they  become  sad,  hypersensitive,  and  irrit- 1 
able.  Their  humour  gradually  becomes  altered.  For  hemiplegic  ■ 
subjects  the  outer  world  has  no  longer  a smile  to  cheer  their  spirits  ; 
everything  is  in  contrast  to  their  own  deplorable  condition,  and.j 
everything  irritates  and  grieves  them,  so  that  they  become  sus-  j 
picious  and  childish.  They  are  easily  moved,  and  some  are  very 
ready  to  fly  into  passions  ; they  become  whimpering  and  irritable,  ^ 
like  little  children.  The  ego  is  harassed  by  the  destroyed  harmony  ^ 
of  the  parts,  and,  as  though  angry  at  the  concord  subsisting  in  the? 
outer  world,  it  turns  upon  itself,  and  between  its  fear  of  greater^ 
evil  and  its  actual  impotence,  takes  to  contemplation  of  itself  more, 
than  others,  and  the  man  who  one  day  was  generous  and  expan- 'I 
sive  becomes  poor  in  spirit,  preoccupied,  egoistic,  and  often  preten- 
tious ; sentiments  of  affection  for  relatives  and  friends  become 
more  enfeebled  in  proportion  as  the  regard  for  one’s  own  person  ^ 
assumes  greater  consistency.  Sometimes  the  sentiments  are  quite 
perverted.  If  to  this  be  added  false  judgment,  which  may  easily . 
come  about  when  family  and  social  relations  are  looked  upon  from . 
a morbidly  egoistic  point  of  view,  there  arise  and  assume  consis-; 
tency  certain  baseless  sympathies  and  antipathies,  quite  irrational,^ 
yet  capable  of  exercising  very  great  influence  upon  the  testamen-j 
tary  dispositions  of  those  subjects  of  whom  we  are  speaking.  Fromi 


POST-APOPLECTIC  DEMENTIA 


851 


the  ethical  point  of  view,  their  conduct  is  not  always  irreproach- 
able. In  this  respect  also,  bearing  in  mind  their  past,  a more  or 
less  considerable  deterioration  is  generally  noticeable,  and  young 
and  old,  if  not  rendered  impotent  by  paralysis,  sometimes  show 
themselves  immoral  or  shameless.  A certain  young  man  suffering 
from  hemiplegia  was  sent  to  the  Naples  Asylum,  because,  though 
formerly  well-behaved,  he  had  become  quarrelsome,  hasty,  eccentric, 
imprudent,  and  even  threatening  towards  his  family,  who  lived  in 
constant  dread  for  some  days  prior  to  his  admission.  In  the 
asylum  he  sought  the  company  of  criminals,  whose  disposition 
harmonized  perfectly  with  his  own. 

This  state  of  matters  often  becomes  slowly  and  progressively 
worse.  The  perceptions  become  more  and  more  torpid  and  incom- 
plete, the  judgments  are  substantially  falsened,  and  the  patients, 
who  are  forgetful  and  intolerably  querulous,  break  out  into  crifes, 
imprecations  and  insults  over  a trifle,  falling  into  absolute  fits  of 
agitation,  with  loquacity,  incoherence,  heightened  colour  of  the 
face,  flashing  eyes,  and  a tendency  to  violence.  In  such  a case  we 
may  speak  of  effective  post-apoplectic  dementia,  with  or  without 
agitation.  The  dementia  sometimes  reaches  a high  degree,  the 
ideation  is  poor  and  ill-connected,  and  the  memory  extremely  weak- 
ened. There  may  be  deliria,  and  these  are  sometimes  systematized. 

In  some  cases  hallucinations  are  developed,  with  all  the  train  of 
phenomena  accompanying  the  hallucinatory  forms  of  psychosis — 
confusion,  agitation,  impulses  or  transitory  states  of  stupor.  It  not 
infrequently  happens  that  patients  of  this  class  are  correct,  clear, 
and  fairly  coherent  during  the  day,  whilst  at  night  they  are  confused, 
out  of  their  bearings,  and  incoherent,  with  a tendency  to  rise  from 
bed  and  wander  about  the  house  in  a dazed  condition  ; or,  where 
there  are  true  oneiric  states,  to  wander  about  the  streets  (Petersen). 

The  hallucinations  may  be  episodic  or  of  long  duration.  These 
patients  furnish  a certain  contingent  to  the  ranks  of  periodical 
insanity,  in  so  far  as  phases  of  agitation  and  of  exalted  emotional 
states,  with  shouting  and  impulsiveness,  follow  one  another  periodi- 
cally. The  dementia  is  either  stationary  from  the  commencement 
or  is  slowly  progressive.  Sometimes  it  progresses  up  to  a certain 
point,  and  then  becomes  stationary  (Kraepelin). 

Some  hemiplegic  subjects  advance  very  rapidly  in  their  dementia, 
when,  as  not  rarely  happens,  the  foci  of  softening  are  complicated 
with  diabetes  or  chronic  nephritis  (intoxication),  and  when  in  old 
persons  the  arterio-sclerosis  or  the  atheroma  is  considerably  ad- 
vanced. These  patients  become  extremely  stupid  and  fllthy  in  their 
habits.  There  is  almost  always  great  mobility  of  emotion,  laughter 
and  tears  being  both  very  ready. 

Destructive  foci  occurring  in  the  brain  during  some  period  or 
other  of  youth,  before  the  mental  development  is  complete,  prevent 
or  misdirect  further  cerebral  development. 


54—2 


852 


PSYCHIATRY 


I have  never  seen  anyone  who  had  become  hemiplegic  in  child- 
hood who  did  not  show  in  adult  age  either  more  or  less  marked  signs 
of  imbecility  or  some  striking  anomalies  of  character.  With 
respect  to  the  psychic  activities,  it  may  be  affirmed  that  destructive 
foci  of  the  brain  are  the  more  insidious  the  younger  the  individual 
affected  by  them.  If,  as  often  happens,  epilepsy  follows  upon 
apoplexy — an  occurrence  that  is  very  frequent  among  the  young, 
and  is  not  at  all  rare  among  adults  and  old  persons — then  there  may  | 
occur  all  those  grave  psychic  anomalies  that  are  so  frequently  met  | 
with  in  epilepsy,  with  this  aggravation,  that  the  effects  are  still  more  ! 
disastrous  in  the  case  of  old  people  whose  brains  are  damaged  and  ; 
weakened. 

It  is  perfectly  clear  that  in  estimating  such  effects,  we  must  take 
into  account  the  functional  rank  of  the  units  that  have  been  sup- 
pressed and  isolated,  the  regions  that  have  been  rendered  inactive 
or  involved  in  the  trouble,  the  compensations,  and  the  variations 
due  to  individual  factors,  in  all  of  which  we  must  seek  the  reason 
why  it  sometimes  appears  that  no  disorder  or  no  lack  of  mental  power 
results  from  lesions  in  certain  cerebral  regions,  even  though  these 
be  sometimes  of  notable  extent,  whilst  very  serious  effects  follow 
from  lesions  in  other  regions,  and  especially  from  lesions  in  the  zone 
of  language. 

Post-apoplectic  dementia  is  always  accompanied  by  very  distinct , 
somatic  phenomena  ; among  them  we  frequently  find  hemiplegia, 
monoplegia,  disturbances  of  sensibility,  hemianopsia,  etc.  (Bianchi, 
La  Emiplegia,  1886  ; Marimu,  Annali  di  Neurologia,  1904).  ; 

It  is  very  difficult  to  explain  the  fact  that  small  capsular  lesions 
produce  comatose  states,  whilst  very  much  larger  cortical  foci,^ 
under  similar  conditions,  do  not  give  rise  to  coma  ; nor  is  it  easy  to  = 
give  any  explanation  of  the  mental  decay,  often  very  conspicuous, 
that  is  found  to  follow  upon  foci  in  the  pons. 

Certainly  the  interruption  of  a large  projection  bundle,  like  that, 
of  the  internal  capsule,  must  have  a reflex  effect  on  the  whole  of  the? 
cerebral  hemisphere,  whose  functions  we  may  consider  as  the- 
physical  basis  of  consciousness.  On  the  other  hand,  the  interruption,- 
in  the  pons,  of  important  associative  paths  between  the  two  cerebrak 
hemispheres,  and  between  these  and  the  cerebellum,  must  isolate 
and  disarrange  very  extensive  cortical  regions  of  the  two  hemispheres, 
or  even  interfere  with  the  whole  cerebral  function.  Meanwhile, 
however,  this  explanation  is  not  more  than  a hypothesis. 

Foci  in  the  zone  of  language  are  more  hurtful  to  the  intelligence 
than  foci  in  any  other  region.  Foci  in  the  frontal  lobes  come  next 
in  importance. 

Circumscribed  foci  of  the  occipital  lobe  frequently  cause  visual 
hallucinations.  Foci  causing  irritation  or  interruption  of  the  fibres 
that  run  through  the  anterior  segment  of  the  internal  capsule  give 
rise  to  spasmodic  laughter  or  weeping,  either  because  irritation  of 

I 


POST-APOPLECTIC  DEMENTIA 


853 


these  fibres  puts  in  tension  the  centre  of  co-ordination  for  mimicry 
in  the  optic  thalamus,  or  because  interruption  of  them  withdraws 
the  centre  of  mimicry  from  the  moderating  and  regulating  influence 
of  the  cortex.  The  same  result  is  obtained  when  the  cortical  centre 
r.  - of  mimicry  is  destroyed  (foot  of  the  ascending  frontal  and  of  the 
g ascending  parietal  convolutions).  In  this  case,  as  in  the  preceding, 
‘ ; the  thalamic  centre  of  mimicry  is  abandoned  to  the  influence  of  all 
^ the  peripheral  stimuli,  no  regulative  or  inhibitory  power  being 
. exercised  upon  it  by  the  cortical  centres  of  the  face  and  the  frontal 
I lobe.  Brissaud,  and  after  him  Mingazzini,  maintained  a similar 
‘ doctrine,  and  up  till  the  present  it  remains  the  most  probable 
explanation. 

' rj  Here  it  is  necessary  to  add  that  anomalous  stimulation  of  the 
thalamus  through  foci  in  its  neighbourhood,  or  incorporated  in  its 
substance,  may  also  give  rise  to  extreme  emotivity,  with  alternations 
of  weeping  and  laughter.  In  two  cases  observed  by  me  these 
: phenomena  had  reached  their  highest  degree.  In  one  hemiplegia  on 
the  left  was  associated  with  hemianaesthesia  (lesion  of  the  posterior 
Rolandic  zone,  or  of  its  projections  into  the  corona  radiata).  In 
. another,  along  with  hemi-paresis  on  the  right,  there  existed  notable 
) homonymous  bilateral  hemianopsia.  In  this  case  the  focus  would 
certainly  be  located  either  in  the  posterior  part  of  the  thalamus  or 
in  the  thalamo-occipital  paths. 

Under  similar  conditions,  lesions  of  the  left  hemisphere  injure 
the  intelligence  much  more  than  those  of  the  right  hemisphere. 
This  difference  is  to  be  accounted  for  by  the  location  of  the  function 
of  language  on  the  left. 

It  has  been  maintained  that  haemorrhagic  foci  disturb  the 
intelligence  much  less  than  softenings.  Mingazzini  has  developed 
this  thesis  much  more  fully  than  any  other  writer,  basing  his  idea 
on  a notably  large  number  of  personal  observations.  As  a rule,  this 
is  true,  and  I adopt  the  proposition  thus  enunciated,  just  as  it  has 
been  implicity  assumed  by  Brissaud,  Gowers,  and  others.  The 
reasons  for  the  difference  in  behaviour  of  the  mind  in  subjects 
affected  by  haemorrhage  on  the  one  hand,  and  those  affected  by 
cerebral  softening  on  the  other  appear  quite  clear.  The  vascular 
anatomico-pathological  substratum  of  cerebral  haemorrhage  is  found 
in  the  miliary  aneurisms  (Charcot  and  Bouchard)  ; whilst  softenings 
are  due,  on  the  other  hand,  to  diffuse  arterio-sclerosis,  with  all  its 
consequences  upon  the  nutrition  of  the  brain. 

Haemorrhage  is,  comparatively  speaking,  more  frequent  at  the 
period  of  life  preceding  old  age,  whilst  softening  is  much  more 
frequent  in  old  age  itself. 

Softenings  are  frequently  complicated,  even  to  a greater  extent 
than  cerebral  haemorrhage,  with  diabetes  and  nephritis.  Again, 
they  are  more  frequent  in  the  cortex,  where  haemorrhage  is  compara- 
tively rare.  All  these  facts  combined  fully  explain  the  frequency  of 


854 


PSYCHIATRY 


mental  decay  in  cerebral  softening  as  compared  with  cerebral  haemor- 
rhage, This  explanation  is  all  the  more  convincing  when  we  con- 
sider that  in  many  cases  mental  decadence  has  already  set  in,  simply 
through  arterio-sclerosis  or  through  senile  cerebral  involution, 
before  the  formation  of  the  focus  of  softening  ; and,  further,  the 
thrombotic  attack  which  brings  about  softening  is  repeated  much 
more  frequently  than  haemorrhage,  and  also  at  shorter  intervals  of 
time.  It  may  therefore  be  legitimately  concluded  that  it  is  not 
owing  to  the  different  nature  of  the  destructive  focus  (haemorrhage, 
thrombosis,  embolism)  that  the  intelligence  of  apoplectics  is  differ- 
ently affected,  but  owing  to  the  different  vascular  and  cerebral  con- 
ditions in  which  the  destructive  foci  are  produced,  and  also  the 
number  and  site  of  these  foci. 

The  pathological  anatomy,  the  prognosis  and  the  therapy  of 
post-apoplectic  dementia,  are  similar  to  those  of  destructive  foci  of 
the  brain,  and  the  general  and  vascular  conditions  in  which  these  are 
produced,  so  that  I must  here  refer  readers  to  treatises  on  the  diseases 
due  to  destructive  foci  in  the  brain. 


CHAPTER  XXXIV 


APHASIC  DEMENTIA 

The  zone  of  language  is  so  closely  connected  with  the  formation  and 
the  expression  of  thought  that  it  may  even  be  presumed  a priori 
that  a lesion  at  any  point  of  this  zone  must  necessarily  have  an  effect 
upon  the  formation  or  the  expression  of  thought. 

Of  the  four  sensory  images  which,  apart  from  mimicry,  prepare 
the  spoken  and  written  expression  of  thought — the  auditory  or 
phonetic,  the  visual,  and  the  kinaesthetic  images  for  both  the  spoken 
and  the  written  word — the  most  preponderant,  which  regulates  and 
governs  the  others,  is  the  phonetic  image,  for  the  already-mentioned 
reason  that,  both  phylogenetically  and  ontogenetically,  it  is  the  first 
to  be  developed,  and  carries  on  its  functions  more  continuously  and 
more  intensely  than  the  others,  which  are  later  in  coming  upon  the 
scene,  and  perform  their  functions  with  more  considerable  interrup- 
tions. In  only  a single  case  does  the  visual  image,  and  therefore  the 
cortical  area  in  which  it  has  been  formed,  assume  great  importance — 
namely,  when  the  art  of  reading,  acquired  in  youth,  has  become  a 
habit  of  life,  and  when,  owing  to  certa  n particular  conditions  of 
heredity  and  environment,  the  verbal  visual  images  have  become 
numerous,  and  have  been  very  frequent  y repeated,  so  that  they 
appear  more  promptly  and  in  the  first  rank  in  the  reproductive 
process  required  for  the  expression  of  thought  Should  this  seem 
at  firs  sight  to  be  simply  a hypothesis,  on  analysis  it  wil'  be  ound 
to  be  susta'ned  and  proved  by  clear  and  incontestable  facts.  A 
case  in  point,  and  one  of  the  most  clearly  demonstrative  that  the 
literature  of  the  subject  possesses,  has  been  reported  by  myself,  with 
necroscopic  proofs 

In  the  first  part  of  this  work  (pp.  126  to  148)  we  have  explained 
as  succinctly  as  possible  the  main  facts  of  the  best  founded  doctrines 
on  the  subject  of  language. 

We  know  that  the  majority  of  men  speak  by  bringing  into  opera- 
tion the  double  arc,  low  and  high,  F'A'A — F'G'G. 

Few  men  speak  with  the  visual  system,  V'A'A — V'G'G,  and 
even  in  such  a case,  which  occurs  only  in  educated  people,  what 

855 


856 


PSYCHIATRY 


most  frequently  occurs  is  that  the  double  system,  auditory  and  visual, 
is  put  in  motion,  with  a preponderance  of  one  over  the  other,  accord- 
ing to  the  more  or  less  prolonged  and  vigorous  exercise  of  the  visual  j 
system.  In  this  way  we  get  an  interlocking  arrangement  of  | 
F'V'A'A  and  V'F'A'A.  In  all  cases  C is  also  intercalated  in  the  I 
course  of  the  psycho-linguistic  waves. 

In  the  case  of  writing,  the  two  systems,  F'G'G  and  V'G'G  enter 
into  action,  because  even  in  visual  subjects  it  is  very  seldom  that  the 
second  can  perform  its  function  without  the  assistance  of  the  first  ; 
in  fact,  the  mechanism  here  may  even  be  more  complex.  There  are 


A F 


Fig.  105. — Scheme  of  the  Mechanism  of  Language  in  Men  who  Read  and  'I 

Write.  -| 

C,  Field  of  concrete  images  and  of  concepts  ; F',  centre  of  phonetic  or  acoustic  ! 
images  of  words  ; V',  centre  of  visual  images  ; A',  centre  of  articulatory  kin- 
aesthetic  images  ; G',  centre  of  graphic  kinaesthetic  images  ; FF'  and  VV',  centri- 
petal paths  for  the  waves  that  form  the  respective  sensory  images  ; A'A  and  I 
G'G,  centrifugal  subcortical  paths  for  the  waves  expressive  of  spoken  and  ; 
written  language  ; CV',  CF',  CA',  CG',  associative  paths  between  the  intel-  | 
lectual  field  and  the  receptive  verbal  centres.  These  paths  must  be  considered  I 
as  duplicated  from  the  intellectual  field  to  the  verbal  images,  and  vice  versa.  ] 
Other  lines  represent  the  associative  paths  between  the  various  sensory  and  j 
motor  centres  of  words.  ^ 

l| 

cases  in  which,  with  a lesion  of  F',  the  regular  function  of  G'  has 
become  impossible,  and  from  that  we  must  conclude  that  even 
lesions  limited  to  F'  may  cause  abolit  on  of,  or  grave  defect  in,  the 
operation  of  wi  iting.  The  reason  for  this  can  readily  be  understood, 
as  G'  simply  works  upon  the  products  of  F'  and  V'. 

Through  this  the  other  mode  of  expression  of  thought  comes 
also  to  be  defective. 

For  psychological  and  clinical  reasons,  it  is  necessary  to  dis- 
tinguish the  verbal-representative  from  the  verbal-expressive  zone. 
Lesions  of  the  representative  zone  are  those  that  do  most  injury  to 


APHASIC  DEMENTIA 


857 


the  intelligence.  The  old  and  vexed  question,  dealt  with  by  Locke, 
Spencer,  Romanes,  and  j\Lix  Muller,  whether  language  is  absolutely 
necessary  to  the  formation  and  the  explication  of  intelligence,  is 
solved  by  a considerable  number  of  carefully  observed  clinical  cases 
that  form  a strong  and  very  practical  contribution  to  the  solution 
of  this  problem,  which  is  one  of  the  most  important  in  cerebral 
physiology  and  psychology. 

In  a work  on  word-deafness  {Rivista  sperunentale  di  Ereniatria, 
1883)  I stated  clearly  the  question  as  to  the  condition  of  the  intelli- 
gence in  this  form  of  aphasia.  ‘ When  it  is  said,’  I then  wrote, 
‘ that  he  who  is  affected  by  word-deafness  seems  to  be  demented, 
but  is  not  really  so,  I believe  this  to  be  an  erroneous  statement  ; 
and  the  error  may  have  arisen  either  from  the  variety  of  cases  or 
from  defect  of  observation.’ 

The  sufferer  from  true  word-deafness  has  the  air  of  a demented 
person,  and  is,  in  fact,  a demented  person  of  a particular  variety, 
distinct  from  all  the  other  well-known  forms  of  dementia.  It  might 
even  be  affirmed  that  he  is  such,  both  in  substance  and  in  form. 
Every  source  of  images  that  determine  thought  is  at  fault,  and  the 
result  must  be  confusion,  for  all  course  of  thought  is  arrested.  It 
may  well  be  doubted  whether  there  is  a definite  thought  present  in 
the  consciousness. 

Thought,  in  so  far  as  it  is  a product  of  synthesis  and  works 
logically  according  to  the  laws  of  association,  does  not  exist  except 
in  the  sensible  form  of  language.  If  language  be  suppressed,  per- 
ception and  immediate  judgments  on  images  are  still  possible  ; not 
so  a train  of  thoughts,  or  an  extended  synthesis. 

With  the  representations  only  of  concrete  images  of  things  we 
can  realize  merely  simple  and  detached  syntheses.  As  a matter  of 
fact,  aphasic  subjects  examined  by  me  did  not  manifest  thought 
in  any  other  way,  neither  by  mimicry  nor  by  gestures,  and  there 
was  no  sign  of  those  changes  of  physiognomy  that  express  the 
working  of  thought  and  the  alternations  of  states  of  consciousness. 
The  sufferer  from  word-deafness  is  often  normal  in  his  conduct, 
and  in  the  sphere  of  the  affective  or  ethical  sentiments,  apart  from 
his  great  emotivity  and  those  cases  in  which  there  is  a form  of 
acute  confusional  psychosis,  of  which  latter  we  shall  proceed  to 
speak. 

The  general  aspect  and  features  of  the  sensory  aphasic  subject 
are  of  a very  plastic  character.  A meaningless  smile  may  flit 
across  his  countenance,  but  as  a rule  he  has  a wan  and  questioning 
look,  and  is  incapable  either  of  conception  or  of  expression.  That 
it  is  right  to  consider  such  a subject  demented  is  proved  by  the 
fact  that  not  only  is  every  source  of  verbal  images,  acoustic  and 
visual,  destroyed,  but,  further,  every  normal  relation  between  words 
that  are  heard  and  the  objects  that  these  words  indicate  or  the 
associations  that  they  involve  is  interrupted. 


858 


PSYCHIATRY 


The  ideas  are  then  in  the  intuitive  state,  just  as  when  in  the 
normal  state  concrete  images  of  things  are  presented  to  the  mind, 
which,  while  they  set  agoing  the  mechanism  for  active  thoughts,  ; 
do  not  give  these  a completed  form  in  which  to  clothe  themselves. 
From  an  examination  of  several  patients  it  appears  to  me  that 
we  may  advance  the  hypothesis  that  in  word-deafness  the  intelli- 
gence is  only  potentially  conserved,  since  it  is  not  disaggregated 
as  regards  the  substantial  formation  of  the  elementary  components, 
as  in  primary  or  consecutive  dementia. 

In  ordinary  dementia  the  degenerative  process,  which  involves 
the  textural  structure  of  the  whole  brain,  tends  to  destroy  the  i 
elementary  components  of  thought.  In  aphasic  dementia,  on  the 
other  hand,  these  last  exist  integrally,  but  the  processes  of  synthesis  i 
are  impeded  in  so  far  as  these  result  from  the  psychological  fusion 
of  the  elementary  components  in  the  word. 

The  abstract  products  of  thought,  therefore,  are  found  to  be 
wanting,  and  all  the  states  of  mind  that  are  connected  with  them. 
The  process  of  abstraction  is  impeded,  and  the  sentimental  tone 
of  the  mind  is  substantially  altered.  Abstractions  are  at  most 
potential,  but  are  buried  in  the  Dead  Sea  of  ‘ the  unconscious,’ 
from  which  they  may  be  raised  and  reconstructed  in  the  field  of 
consciousness,  provided  always  this  sphere  is  reached  by  the  re- 
spective sensible  form,  with  all  its  associative  relations.  Confirma- , 
tion  has  been  given  to  this  concept  by  several  cases,  almost  experi- 
mental in  value,  of  aphasic  dementia  from  word-deafness  or  blind-  ^ 
ness,  with  or  without  paraphasia,  following  upon  temporal  lesions, ; 
or  lesions  of  the  angular  gyrus  (optic  aphasia),  lesions  which  were 
equivalent  to  the  most  rigorous  experimental  investigation.  ^ 

Observation  XXXVII. — The  case  is  that  of  a woman  who  was  I 
admitted  into  the  cliniqUe  in  a state  of  great  confusion  and  psycho-motor 
agitation.  After  observing  her  carefully,  I managed  to  ascertain  that, 
the  confusion  and  agitation  were  due  to  her  being  affected  by  word-  ’ 
deafness.  She  understood  only  a few  of  the  words  that  were  addressed^ 
to  her.  There  was  also  complete  word- blindness  (word-blindness  withj 
agraphia).  This  woman  had  been  a teacher,  and  not  only  did  she  know^ 
Italian  well,  but  also  French,  and  in  addition  she  had  taught  music.'] 
Subsequent  examination  brought  out  clearly  the  fact  that  she  had  com-i 
pletely  forgotten  music  (amusia),  so  that  not  only  did  she  fail  to  recognise 
written  words  (alexia),  but  she  did  not  even  know  the  musical  notes. 
The  word-deafness  improved,  but  word-blindness  remained  complete, 
with  homonymous  bilateral  hemianopsia  on  the  right,  complete  agraphia, 
and  extreme  poverty  of  language,  sometimes  with  paraphasia. 

The  diagnosis  was  word-blindness,  with  incomplete  word-deafness, 
due  to  a destructive  focus  in  the  angular  gyrus  and  the  surrounding  zone, 
extending  to  the  thalamo-occipital  optic  radiations. 

Three  months  before  she  died  she  was  attacked  by  vertigo  (the  | 
malady  had  commenced  with  attacks  of  vertigo,  which  had  come  upon  * 
this  woman  when  her  general  and  mental  conditions  were  quite  satis-  j 
factory).  ! 


APHAKIC  DEMENTIA 


859 


After  this  second  attack  of  vertigo  she  had  complete  word-deafness. 
She  did  not  now  understand  a single  word,  whilst  before  the  attack  she 
had  understood  several.  She  fell  into  a state  of  absolute  indifference 
and  apathy.  She  no  longer  expressed  a single  thought  or  manifested  a 
desire  or  want.  She  did  not  pronounce  a single  word,  even  though  urged 
to  do  so.  In  short,  her  state  was  one  of  complete  dementia,  and  she 
shortly  afterwards  died. 

At  the  autopsy  I found  on  the  external  aspect  of  the  left  hemisphere 
two  foci,  one  limited  to  the  middle  and  posterior  part  of  the  first  temporal 
convolution,  and  to  a small  section  of  the  second,  whilst  the  other  was 
in  the  angular  gyrus,  extending  a little  over  the  marginal  convolution. 
On  the  right  hemisphere  another  focus  was  observed,  perfectly  sym- 
metrical with  the  one  found  in  the  left  temporal  convolutions.  The 
lesion  on  the  right  was  rather  deep,  as  was  also  the  focus  on  the  left, 
reaching  almost  to  the  lateral  ventricle. 

From  the  macroscopic  examination  it  could  be  inferred  that  the  focus 
in  the  right  hemisphere  was  the  older  of  the  two,  since  it  was  cystic,  with 
cicatricial  cords  traversing  the  cavity,  whilst  those  in  the  left  temporal 
convolution  and  inferior  parietal  lobe  were  much  more  recent.  Evidently 
these  lesions  were  the  explanation  of  the  clinical  complexes  that  we 
found.  The  lesions  in  the  two  first  temporal  convolutions,  right  and 
left,  accounted  for  the  grave  word-deafness  into  which  this  woman  had 
fallen  toward  the  close.  It  is,  of  course,  known  that  when  the  lesions 
are  bilateral  and  symmetrical,  the  aphasia  is  grave  and  complete.  The 
lesion  of  the  parietal  lobe  is  certainly  the  explanation  of  the  homonymous 
bilateral  hemianopsia  of  the  opposite  side,  and  of  the  word-blindness, 
which  further  might  also  be  considered  as  a consensual  symptom  of  the 
cortical  word-deafness.  The  same  focus  affords  the  explanation  of  the 
grave  dementia  from  which  this  woman  suffered.  To  tell  the  truth, 
as  this  was  the  case  of  an  educated  woman,  who  had  been  a teacher  for 
many  years,  and  as  in  the  course  of  time  it  appeared  that  the  word- 
deafness  had  improved  with  exercise,  I had  attributed  the  whole  syrnpto- 
matic  complexus  to  a lesion  of  the  angular  gyrus,  being  led  to  that  opinion 
by  the  persistency,  without  any  sign  of  improvement,  of  all  the  symp- 
toms of  word-blindness  and  hemianopsia,  whilst  the  word-deafness  had 
been  gradually  improving.  It  was,  therefore,  permissible  to  suppose 
that  the  dementia  arose  from  a lesion  of  the  angular  gyrus  in  a subject 
who,  as  she  had  read  a great  deal,  had  been  obliged  to  use  a considerably 
greater  number  of  visual  than  of  auditory  images  in  her  processes  of 
thought.  Word-deafness  in  this  case  might  well  have  arisen  from  the 
lesion  of  the  inferior  parietal  lobule  through  interdiction  of  the  auditory 
centre,  and  not  from  a coexisting  lesion  of  the  first  temporal  convolution. 
This  was  rendered  probable  by  the  existence  of  genuine  forms  of  word- 
blindness,  with  grave  dementia  and  other  symptoms.  We  may  well 
admit  that,  in  those  subjects  who  have  had  much  exercise  in  reading, 
and  who  learn  principally  by  reading,  complete  word-blindness  is  accom- 
panied by  formative  and  expressional  disturbances  of  speech,  and  by 
profound  mental  disturbance  (aphasic  dementia).  It  is  clear,  however, 
that  in  this  case  a portion  of  the  syndrome  must  be  ascribed  to  the  right 
temporal  lesion.  This  woman  must  have  been  visual  in  part  only,  and 
yet  the  grave  dementia  cannot  be  put  down  exclusively  to  the  lesion  of 
the  parietal  lobe,  for  a part  must  be  attributed  to  the  temporal  lesion 
on  the  right.  It  must  be  considered  that  the  right  hemisphere  takes 
part  in  the  psycho-somatic  process  of  speech,  for  there  are  a considerable 
number  of  observations  on  aphasia  (partial  or  incomplete  aphasia)  from 
a focal  lesion  in  the  zone  of  language  in  the  left  hemisphere,  which  becanie 
extremely  grave  and  complete  later  on,  when  a focus  had  also  formed  in 


86o 


PSYCHIATRY 


1 


the  right  hemisphere.  The  present  case  is  a proof  of  that.  The  patient 
had  already  had  a cerebral  attack,  with  the  formation  of  a destructive 
focus  on  the  right  hemisphere,  which  certainly  had  occurred  a long  time 
before  she  was  admitted  into  the  asylum.  On  her  second  seizure,  the 
mental  disturbance  was  such  that  she  had  to  be  taken  to  the  asylum. 
At  this  point  it  is  doubtful  whether  the  second  focus  was  that  of  the 
temporal  lobe  or  of  the  parietal  lobule  on  the  left  side,  because,  when 
admitted,  the  patient  showed  word-deafness  and  word-blindness,  and 
it  was  only  when  she  had  had  her  last  attack,  towards  the  close  of  her 
stay  in  the  asylum,  that  she  became  completely  aphasic  and  demented. 
We  might  summarize  her  clinical  and  pathological  history  thus  : the 
first  focus  was  formed  in  the  right  hemisphere,  in  the  temporal  lobe  ; 
the  second  in  the  angular  gyrus  on  the  left,  which  brought  about  the 
word-deafness,  either  through  its  proximity  to  the  auditory  centre  of 
speech,  or  through  the  persistent  lesion  of  the  right  temporal  zone  ; the 
last  lesion  occurred  in  the  left  temporal  lobe,  and  then  all  mental  activity 
whatsoever  was  suppressed. 

Observation  XXXVIII. — The  following  is  a case  which  is  still  more 
conclusive  than  the  foregoing,  owing  to  the  limited  area  occupied  by  the 
lesion  : The  patient  was  received  into  the  clinique  in  a state  of  almost 
complete  dementia  and  a prey  to  extreme  agitation.  He  talked  cease- 
lessly, became  excited,  struck  himself  on  the  head  with  his  fists,  and 
inveighed  against  others  ; but  he  could  not  manage  to  formulate  a single 
phrase. 

He  had  fallen  into  this  state  almost  instantaneously,  without  any 
premonitory  symptoms.  His  agitation  abated  considerably,  and  when 
it  became  possible  to  examine  him,  we  found  the  classic  picture  of  word- 
deafness.  The  subject  did  not  understand  a single  word,  not  even  the 
simplest,  that  was  addressed  to  him,  and  he  spoke  only  unintelligible  ^ 
fragments  of  words.  He  presented  no  visual  disturbance.  He  saw  < 
everything,  understood,  and  could  make  visual  movements,  but  with  : 
words  it  was  impossible  to  make  him  understand  anything  at  all.  He 
expressed  not  the  slightest  thought  or  sentiment.  His  mind  was  in  a ' 
static  condition,  but  was  at  the  same  time  vacant  (dementia).  He  ! 
remained  in  this  state  for  two  weeks,  and  then  died  of  pneumonia. 

At  the  autopsy  the  only  lesion  found  was  a focus  of  softening  in  the  ; 
first  left  temporal  convolution,  and  this  softening  extended  in  a rather 
less  degree  as  far  as  the  angular  gyrus.  All  the  rest  of  the  hemisphere  ; 
was  sound,  as  was  also  the  right  hemisphere.  ^ 

Observation  XXXIX. — B.  C.,  following  upon  an  attack  of  indigestion,  \ 
was  suddenly  seized  with  violent  trembling  of  the  whole  body,  followed  by  j 
convulsive  movements  of  the  limbs,  which  were  accompanied  by  loss  ^ 
of  consciousness.  This  attack  lasted  for  some  hours,  and  was  succeeded  * 
by  a state  of  torpor,  from  which  he  awakened  with  complete  right-sided 
hemiplegia.  He  commenced  to  recovei  slowly  after  about  ten  days, 
but  the  persons  'around  him  observed  that  he  had  almost  completely 
lost  the  power  of  speech,  and  could  pronounce  only  with  difficulty  a 
very  few  words,  such  as  ‘ mangiare,’  ‘ here,’  etc.  (eat,  drink,  etc.).  These 
troubles  were  gradually  alleviated  in  part,  until  the  patient  reached  the 
condition  in  which  I examined  him. 

Since  his  last  attack  he  had  shown  some  defect  of  observation,  and 
would  readily  mistake  a balcony  for  a door.  He  had  suffered  also 
from  marked  disturbances  of  memory,  and  exaggerated  emotivity,  with 
facile  and  disproportionate  motor  reaction.  For  these  reasons  he  was 
taken  to  the  asylum.  He  could  scarcely  see  with  the  left  eye,  owing  to 


APHASIC  DEMENTIA 


86i 


cataract.  With  the  right  his  power  of  vision  was  extremely  limited,  and 
even  at  a short  distance  objects  were  confused  and  ill  defined,  whilst  he 
frequently  mistook  a coin  of  five  centesimi  for  one  of  ten,  or  for  a lira. 
He  easily  recognised  all  colours  except  blue,  which  he  could  not  dis- 
tinguish at  all.  His  field  of  vision  was  restricted,  and  there  was  hemiopia 
on  the  right. 

The  muscular  force,  both  in  the  upper  and  in  the  lower  limbs,  was 
fairly  well  preserved. 

The  dynamometric  indications  were  : right  hand,  38  ; left  hand,  40. 
His  walk  was  slow,  but  not  uncertain  ; he  raised  his  feet  but  little  when 
stepping,  and  the  soles  of  the  feet  slightly  scraped  the  ground.  This 
was  not  paralysis,  but  the  walk  of  a man  in  a state  of  debility.  It  was 
impossible  for  him  to  balance  himself  on  one  foot,  even  with  his  eyes 
open. 

This  man,  who  had  been  a printer  from  his  youth,  and  had  gone 
to  Naples  specially  to  set  up  a printing-ofhce  there,  must  consequently 
have  been  enterprising,  educated,  and  of  more  than  average  intelligence. 
So  much  might  be  judged  from  the  fragments  of  speech,  from  his  eye, 
that  tried  to  express  so  much,  from  his  open  and  sympathetic  face,  from 
his  consciousness  of  his  actual  condition,  in  contrast  with  what  it  had 
been,  as  he  himself  said.  He  would  burst  into  tears  and  fall  into  despair 
at  being  reduced  to  such  a state  of  ignorance,  and  at  his  inability  to 
express  a single  thought. 

As  a matter  of  fact,  he  understood  everything  that  was  said  to  him, 
as  was  proved  by  his  words  and  gestures.  Sometimes  he  was  slow  in 
answering,  and  at  other  times  it  was  necessary  to  repeat  words  to  him, 
but  he  always  ended  by  receiving  and  understanding  them.  His  own 
speech,  however,  was  broken  and  fragmentary,  and  most  frequently, 
after  commencing  a phrase  with  a pronoun,  a verb,  or  some  adverb,  he 
stopped,  and  could  go  no  further.  He  was  unable  to  help  himself,  even 
by  the  use  of  periphrasis.  The  object  escaped  him,  in  consequence  of 
which  he  was  so  much  grieved  that  he  would  commence  to  weep,  repeating 
over  and  over  again,  ‘ But  I used  to  know  that  quite  well  ; why  don’t 
I know  it  now  ?’  ‘ I have  repeated  that  so  many  times.’  ‘ What  is  to 

become  of  me  ?’ 

If  the  word  that  he  was  seeking  were  suggested  to  him,  he  would  repeat 
it  at  once  with  pleasure  and  satisfaction,  whilst  his  eye  would  gleam  for 
a moment.  Thus  he  remained  : his  language  became  impoverished,  even 
in  the  use  of  words,  and  especially  in  names  of  persons,  places,  and  things, 
so  that  at  last  he  could  not  even  remember  his  own  name.  His  articula- 
tion of  spontaneous  or  suggested  words  was  perfect,  with  the  exception  of 
a few  paraphasic  errors,  which,  however,  he  corrected  if  his  attention 
were  drawn  to  them,  and  sometimes  even  spontaneously. 

If  a piece  of  printed  or  written  matter  were  put  before  him,  he  could 
not  read  it,  being  unable  to  make  out  either  word  or  syllable.  Further, 
if  the  syllable  that  he  did  not  manage  to  read  were  suggested  to  him,  he 
would  repeat  it  as  some  phonetic  symbol  that  he  had  heard,  but  he  did 
not  read  it,  and  he  could  not  persuade  himself  that  the  letters,  in  their 
union  as  graphic  symbols,  formed  the  syllable.  For  him  the  letters  had 
lost  their  significance  as  component  parts  of  syllables  and  of  words. 
Sometimes  he  managed  to  read  a syllable  or  two,  but  it  was  impossible 
for  him  to  associate  several  syllables,  and  this  even  of  the  few  that 
he  managed  to  read  with  difficulty.  Further  than  that,  perhaps 
he  would  recognise  some  letter  in  a word,  or  several  letters,  and  out 
of  these  he  would  form  a word  for  himself,  but  not  at  all  corresponding 
with  the  word  under  his  eye.  He  thus  furnished  a classic  example  of 
paralexia. 


862 


PSYCHIATRY 


Here  are  some  specimens  : 

Fazzoletto 

Bottone 

Catena 

Sfera 

Chiave 

Coltura 

Boccetta 

Campana 

Vetro 

Sughero 

Giornale 


luciolo 

giappon 

giocan 

alfabeto 

atrio 

suola 

traversa 

stampa 

ferro 

strada 

inotalio 


His  spontaneous  writing  was  unintelligible.  It  was  only  with  difficulty 
that  he  could  write  even  his  own  name,  for  he  distorted  that  and  every 
other  word  (dysgraphia  with  paragraphia).  He  wrote  well  to  dictation. 

He  died  on  the  morning  of  December  4,  after  another  cerebral  attack, 
and  an  autopsy  was  made  twenty-two  hours  after  his  decease.  The 
following  lesions  were  found  : 

On  the  right  hemisphere — 

1.  A small  focus  of  softening  in  the  external  segment  of  the  lenticular 
nucleus. 

2.  A small  focus  of  softening  in  the  white  substance  of  the  first  frontal 
convolution,  in  front  of  the  foot  of  that  convolution. 

3.  An  old  focus  of  softening  in  the  convolution  of  the  corpus  callosum, 
corresponding  in  position  to  the  splenium,  and  extending  upwards  over 
the  lower  third  of  the  lobus  quadratus  or  precuneus,  and  going  deep  into 
the  gray  substance. 

On  the  left  hemisphere  : An  old  focus  of  softening,  corresponding  in 
site  to  the  angular  gyrus.  This  was  particularly  destructive  to  the  gray- 
substance  of  the  posterior  part  of  the  first  temporal  sulcus,  just  where  it; 
terminates  in  the  angular  gyrus.  This  focus  spared  the  first  and  second 
temporo-sphenoidal  convolutions  completely,  and  went  deeply  into  the 
white  substance  of  the  angular  gyrus,  as  far  as  the  posterior  cornu  of  the! 
lateral  ventricle. 

There  was  nothing  noteworthy  in  the  remainder  of  the  left  hemisphere, 
in  the  mesencephalon,  or  in  the  cerebellum. 

The  syndrome  constituted  by  the  alexia,  paraphasia,  dysgraphia,  and, 
the  grave  amnesia  that  characterized  the  dementia  of  this  man,  was  to  be. 
attributed  to  the  lesion  of  the  angular  gyrus  on  the  left.  Since  he  had^ 
done  the  work  of  a printer  for  forty  years,  we  may  suppose  that  the| 
visual  centre  for  words  had  become  the  great  workshop  for  the  fusion  of^ 
thought  with  word.  The  destruction  of  this  workshop  was  the  cause  of  his^ 
very  severe  and  irreparable  mental  disaster.  ^ 

In  such  cases  we  have  almost  invariably  to  deal  with  cultured  indi-  j 
viduals — speakers,  teachers,  judges  of  the  higher  courts — almost  always  j 
with  men  who  make  great  use  of  words,  who  become  demented  instan-  i 
taneously.  In  addition  to  the  cases  published,  I mention  two  that  have  I 
come  under  my  notice  quite  recently. 

Observation  XL. — A professor  of  literature  was  one  day  seized  with  I 
vertigo  after  giving  his  lesson.  At  the  same  time  he  felt  a tingling  and  | 
some  numbness  in  his  right  limbs.  He  was  taken  home,  but  to  the  j 
members  of  his  family  he  could  hardly  express  what  he  felt  or  what  he  , 
wished  in  an  intelligent  fashion.  His  greatest  difficulty  was  to  find  words, 
which  failed  him  almost  completely,  with  the  exception  of  the  most 
common  and  vulgar  expressions,  these  being  sometimes  pronounced  out  j 


APHASIC  DEMENTIA 


863 


of  place.  At  the  same  time,  he  became  extremely  confused,  and  rather 
agitated.  In  the  course  of  a week  his  agitation  gradually  disappeared,  as 
also  the  hemiparesis,  but  he  had  forgotten  his  whole  vocabulary.  He 
was  a man  most  learned  in  literature,  and  knew  by  heart  almost  all  the 
cantos  of  Dante.  After  the  attack  of  vertigo  he  did  not  recollect  even  a 
single  verse,  and  this  drove  him  to  desperation.  He  could  not  even  name 
any  of  the  commonest  objects.  He  was  hemiopic  on  the  right.  He 
passed  his  days  in  a state  of  indifference,  as  one  stunned,  and  as  though  his 
consciousness  were  a mere  void.  In  two  months  he  had  not  shown  very 
much  improvement. 

Observation  XLI. — One  of  our  most  distinguished  judges,  in  the  full 
vigour  of  health,  passed  his  holidays  in  Naples,  and  was  starting  home 
again.  He  left  his  house  one  autumn  evening,  and  secured  a passage  on  the 
steamer,  but  before  it  left  he  had  a fit  of  vertigo.  He  did  not  fall  down, 
but  lost  his  bearings.  He  could  not  pull  himself  together  again,  either 
in  thought  or  in  words.  Not  only  was  he  unable  to  formulate  a phrase, 
but  even  the  few  words  that  he  did  pronounce  were  distorted.  He  went 
ashore  again  before  the  steamer  left,  and  after  he  had  reached  home  I was 
called  in  to  see  him.  On  examining  him,  I found  no  disturbance  of 
motion,  for  he  walked  perfectly  well,  and  could  use  both  hands  just  as 
before  his  attack.  On  the  day  following  his  attack  of  vertigo  he  was 
conscious  of  a certain  degree  of  numbness,  which,  however,  disappeared. 
I found  only  that  the  patellar  reflex  on  the  right  was  slightly  exaggerated. 
There  was  bilateral  homonymous  hemianopsia  on  the  right,  and  almost 
complete  alexia  for  words  and  for  letters,  so  that  he  could  not  spon- 
taneously write  a single  word  in  its  correct  form  (dysgraphia).  It  was 
impossible  for  him  to  copy.  He  could  write  a few  phrases  to  dictation, 
but  with  difficulty.  There  was  no  word-deafness,  but  it  was  necessary  to 
speak  plainly,  and  sometimes  to  repeat  phrases,  in  order  that  he  might 
understand  them.  His  own  speech  was  reduced  to  broken  and  distorted 
phrases,  made  up  of  words  that  were  almost  all  mangled.  He  was  con- 
fused, and  could  not  express  a single  thought,  even  by  mimicry  or  by 
signs.  He  would  often  smile,  and  when  not  speaking  he  appeared  to  be 
sane,  composed,  correct,  and  gentlemanly  ; but  he  had  forgotten  almost 
every  word,  and  all  his  vast  knowledge  and  learning  were  effaced.  This 
patient,  who  had  been  a most  studious  man,  had  become  vacant.  Cer- 
tainly he  was  a visual  subject,  and  the  variety  of  aphasia  with  which  he 
was  affected  could  be  defined  as  optical  aphasia  with  paraphasia,  para- 
phrasia,  and  dementia  (aphasic). 

Other  similar  cases  have  been  published  by  me  {Annali  di  Neurologia, 
1892  ; Policlinico,  1894  ; Trattato  delle  malattie  del  cervello,  in  the  Pato- 
logia  Speciale  of  Maragliano  e Cantani,  1901). 

In  the  face  of  clinical  observations  of  this  sort,  and  of  discoveries 
on  functional  localization  in  the  cerebral  cortex,  the  period  of 
introspective  discussion  closes,  and  the  dawn  of  a new  and  more 
fruitful  era  is  foreshadowed  by  the  accumulation  of  facts  that  are  of 
immense  value  for  psychology. 

When  Locke  expressed  himself  on  the  relations  between  intelli- 
gence and  language  in  the  clearest  and  most  precise  terms,  saying, 
‘ We  have  reason  to  imagine  that  they  (brutes)  have  not  the  faculty 
of  abstracting  or  making  general  ideas,  since  they  have  no  use  of 
words  or  any  other  general  signs,’  he  saw  a great  truth,  but  it 
lacked  objective  proof.  The  same  may  be  said  of  the  thoughts 


864 


PSYCHIATRY 


that  fell,  like  ripe  fruits,  in  the  domain  of  Science,  from  the  dis-  i 
cussions  about  nominalism,  carried  on  by  Berkeley,  Mill,  Romanes,  j 
and  others.  These  results,  which  were  the  work  of  speculation, 
could  not  enjoy  the  fortune  of  final  acceptance  (this  applies  to  all 
products  of  introspection)  unless  validity  were  given  to  them  by 
objective  observation.  Although  Romanes  held  that  the  process 
of  thought  was  a development,  that  the  faculty  of  abstraction,  which 
is  always  of  the  same  species  and  is  an  evolution,  was  wholly  depen- 
dent on  the  faculty  of  language  ; though  Taine  declared,  with  great  | 
lucidity,  that  we  conceive  characters,  abstracted  from  things,  by 
means  of  abstract  names,  which  are  our  abstract  ideas,  and  that 
the  formation  of  abstract  ideas  is  nothing  more  than  the  formation  ^ 
of  names,  we  may  well  affirm  that  these  great  conceptions  lacked  the  | 
certificate  of  authenticity  that  canTe  given  them  by  clinical  observa-  I 
tion  and  by  anatomo-pathological  findings,  which  have  proved  that, 
if  the  cerebral  area  in  which  are  registered  the  sensory  images 
(auditory  and  visual)  of  words  be  destroyed  or  interdicted,  then 
the  source  of  all  abstract  ideas  is  suppressed ; for  these  abstract 
ideas,  even  if  they  exist  potentially,  do  not  venture  to  cross  the 
threshold  of  consciousness,  or,  if  we  desire  to  express  ourselves 
with  greater  precision,  they  cannot  be  reproduced,  because  move- 
ment of  abstract  thought  is  not  realizable  except  through  sensible 
forms,  and  these  are  words. 

Quite  recently  H.  Gomperz  {Zur  Psychologic  der  logischen  ' 
Grundthatsachen,  Leipzig,  1897)  has  treated  this  question  with  ^ 
great  acumen,  and  he  has  come  to  conclusions  identical  with  those  ^ 
that  I had  published  ten  years  before  on  the  basis  of  clinical  obser-  ' 
vat  ions.  He  maintains  that  the  being  who  is  not  endowed  with 
language  will  not  be  able  to  form  general  ideas  or  abstract  ideas,  , 
propositions,  or  reasonings.  Such  a being  will  be  conscious  only  of 
sensible  images.  ; 

It  might  be  objected  that  the  state  of  some  sufferers  from  word- 
deafness  is  very  grave  when  there  is  a defect  of  the  sensible  forms  . 
of  thought  (almost  all  the  nouns,  and  many  adjectives  and  verbs),  | 
although  they  preserve  intact  and  reproducible  the  empirical  and  ^ 
concrete  images  of  objects,  places,  events,  etc.,  whilst  many  im-  ; 
beciles,  who  have  a very  poor  vocabulary,  and  nothing  at  all  in  the  <1 
way  of  abstract  ideas,  and  whose  stock  of  concrete  and  empirical  i 
images  is  much  less  than  that  which  is  possessed  by  a man  affected 
with  word-deafness,  nevertheless  appear  to  be  more  intelligent. 
That  might  lead  us  to  consider  that  the  dementia  of  these  subjects  ' 
is  to  be  attributed  not  to  the  word-deafness  or  word-blindness,  1 
but  to  some  other  circumstance.  No  one  will  deny  that  other  cir- 
cumstances can  impart  the  most  diverse  characters  to  the  clinical  , 
picture.  The  extent  of  the  focus,  its  depth,  and  consequent  inter-  | 
ruption  of  numerous  associative  paths  ; the  greater  or  less  partici-  | 
pation,  material  or  functional,  of  the  areas  surrounding  the  language  i 


APHA.^IC  DEMENTIA 


865 


part  that  has  been  injured  ; the  greater  or  less  loss  of  mnemonic 
capital  accumulated  by  other  senses,  and  the  effect  of  the  cerebral 
lesion  itself  and  the  shock  that  results  from  it,  are  so  many  causes 
of  different  behaviour  on  the  part  of  sensory  aphasic  subjects. 
Add  to  this  the  difference  between  a being  who  has  not  reached 
the  height  of  abstract  thought,  represented  by  language,  and 
another  who  has  moved  in  the  sphere  of  abstraction,  of  which  he 
has  lost  the  dominion,  as  the  result  of  destruction  of  the  phonetic 
area  of  the  cerebral  mantle. 

Whilst  the  imbecile,  and  even  the  idiot,  utilize  their  modest 
mental  patrimony,  co-ordinating  it  with  the  immediate  needs  of 
their  lives,  individuals  who  are  intellectually  well  endowed,  and 
who  live  their  mental  lives  in  the  most  elevated  and  most  extensive 
spheres  of  nominalism  and  conceptualism,  are  put  out  of  their 
bearings  when  this  field  is  closed  to  the  mechanism  of  the  forma- 
tion and  expression  of  thought.  No  longer  can  any  of  the  products 
of  the  mind  be  utilized,  and  these  subjects  appear  to  be  amnesic. 
It  is  as  if  all  the  separate  parts  of  a complicated  mechanism  were 
prepared  in  their  respective  workshops,  while  there  is  wanting  a 
workshop  with  the  special  operators  to  put  the  parts  together,  so 
as  to  form  a complete  piece,  ready  to  work. 

These  sufferers  have  only  a confused  consciousness  of  their 
trouble,  and  often  they  appear  to  be  perfectly  satisfied  with  them- 
selves, or  they  present  all  the  phenomena  of  mental  confusion,  with 
the  addition  that  they  frequently  distort  the  words  they  employ  to 
express  images  and  states  of  emotion. 

When  general  ideas  have  been  violently  suppressed,  the  affec- 
tive and  emotional  colouring  of  these  ideas  also  disappears  in  great 
part.  In  this  state  they  canno-t  grasp  the  meaning  of  the  speaker, 
even  though  they  understand  a few  words,  nor  can  they  themselves 
formulate  a clear  thought.  Often  they  are  grieved  thereat,  but  in 
most  cases  they  remain  simply  like  the  plastic  figures  in  a marionette 
show,  motionless,  impassible,  vacant,  or  wondering — true  points  of 
interrogation  in  the  mute  and  solemn  language  of  a clinique  of  nervous 
sufferers. 

Sometimes  dementia  of  this  order  is  accompanied  by  extreme 
psycho-motor  agitation.  In  recent  years  I have  observed  two 
cases  of  educated  persons  who,  overtaken  by  brain  troubles,  throm- 
botic or  haemorrhagic,  resulting  in  word-deafness,  showed  great 
confusion  and  psycho-motor  agitation.  In  one  of  these  cases  there 
were  clear  signs  of  delirium  of  persecution,  with  threats,  impulses, 
and  great  agitation.  These  were  mingled  with  paraphasic  and 
dysphrasic  phenomena.  On  careful  examination  there  was  found 
nothing  more  than  grave  and  complete  word-deafness,  and  from 
this  arose  the  psycho-motor  excitement.  If  the  lesion  is  not  very 
extensive,  and  if  the  patient  be  re-educated,  his  re-education  tend- 
ing to  renew  the  auditory  verbal  relations  with  the  external  world, 

55 


866 


PSYCHIATRY 


then  the  agitation  disappears,  and  the  intelligence  is  reawakened. 
These  are  the  cases  of  compensation,  when  the  foci  are  small,  or 
when  there  exist  individual  dispositions  allowing  of  compensation 
by  the  right  hemisphere,  the  influence  of  which,  I here  repeat, 
cannot  be  denied  in  the  function  of  language. 

When  the  above  is  not  possible,  the  agitation,  and  particularly 
the  confusion,  which  is  often  serious,  last  for  a long  time. 

Every  word  that  a sufferer  from  sensory  aphasia  learns,  means 
a more  or  less  general  idea,  and  in  the  consciousness  of  the  indi- 
vidual it  fills  up  a void,  represented  by  a negative  sensation  of  the 
loss  of  something  that  the  person  had  formerly  possessed.  The 
personality  is  reintegrated  little  by  little,  by  every  word  with  which 
the  vocabulary  is  enriched,  like  an  edifice  that  has  been  overthrown 
by  an  earthquake  and  is  built  up  again  with  the  same  materials, 
stone  upon  stone,  on  the  same  foundations,  and  with  the  same 
architectural  plan. 

One  of  our  patients,  whose  vocabulary  had  been  effaced  all  at 
once,  and  who  was  reduced  to  such  a state  that  he  was  incapable 
of  writing  even  his  own  name,  although  there  was  no  trace  of 
paralysis,  gradually  recovered  the  ability  to  write,  in  proportion  as 
his  mnemonic  capital  of  words  was  revived.  In  order  to  write 
the  words,  it  was  not  sufficient  that  he  should  be  able  simply  to 
articulate  them  ; it  was  necessary  that  he  should  understand  them, 
associating  with  them  the  images  of  the  objects,  of  their  qualities 
and  their  relations,  thus  rising  again  into  intellectual  life.  The 
same  thing  happens  with  the  ability  to  read,  which  is  recovered 
only  after  the  pages  of  one’s  vocabulary  have  been  refilled.  In 
that  process  of  re-education  I could  confirm  what  I had  already 
observed— namely,  that  the  acoustic  image  reawakens  the  visual 
image  of  syllables  and  words,  as  well  as  the  graphic  image, 
by  way  of  the  ideative  field  ; that  is  to  say,  that  the  phonetic 
image  ^ per  se  does  not  reawaken  the  graphic  and  the  visual 
image  until  after  it  has  itself  been  associated  with  the  cor- 
relative idea,  forming  a coalescent  whole  of  real  intellectual  value. 
It  is  then  that  the  behaviour  of  the  patients  is  observed  to  change. 
One  of  these  sufferers,  when  he  had  regained  consciousness  of  him- 
self, by  virtue  of  the  reacquired  power  of  speech,  permitting  the 
movement  of  thought  that  was  formerly  inhibited,  came  to  recog- 
nise his  real  relations  with  the  external  world,  and,  as  though 
awakening  from  a sleep  that  had  overwhelmed  him  for  a long 
time,  he  remembered  his  family,  his  social  position,  his  profession, 
his  duties,  his  ability  to  earn  all  that  was  required  for  their  needs, 
also  the  impropriety  of  continuing  to  live  at  the  cost  of  the  asylum. 
He  conceived  a strong  and  rational  desire  for  liberty,  whilst  he  was 
grateful  for  all  that  had  been  done  for  him.  His  look  became  more 
mobile  and  intelligent  and  his  physiognomy  more  expressive  and 
composed  as  events  unrolled  before  him.  He  had  a perfect  kncw^ 


APHASIC  DEMENTIA 


867 


ledge  of  persons,  places,  and  circumstances,  and  he  could  explain 
everything  in  the  small  sphere  of  his  life.  There  was  much  still 
to  be  regained  by  him  when  I dismissed  him  from  the  asylum,  but 
he  had  already  gained  much,  and  his  personality,  if  not  wholly 
reintegrated,  was  certainly  recomposed  in  its  general  lines.  In 
such  cases  we  must  not  neglect  to  take  into  consideration  that 
degree  of  intellectual  decadence  to  which  almost  all  individuals 
affected  by  a malady  due  to  destructive  focus  of  the  brain  may  be 
subject. 

In  cases  of  pure  aphasia,  then,  we  may  be  guided  by  the  same 
scheme  that  has  served  to  enable  us  to  understand  the  various  forms 
of  aphasia. 

I.  Simple  agraphia  due  to  lesion  of  G',  or  of  the  afferent  paths, 
does  not  involve  any  appreciable  disturbance  of  the  intelligence 


Fig.  106. — Topography  of  the  Zone  of  the  Neuropsychic  Factors  of 

Language. 

F , acoustic  zone  ; V , visual  zone  ; A'’,  motor  zone,  for  the  spoken  word  ; pre- 
sumed motor  zone  for  writing  ; C,  intellectual  field,  which  in  this  scheme  is 
represented  only  by  the  frontal  lobe,  but  comprises  ali  the  sensory  zones,  whose 
reciprocal  relations  with  the  field  of  speech  have  been  omitted,  in  order  to  make 
the  figure  clearer. 


and  of  the  personality,  because  the  intellectual  patrimony  can  be 
reproduced  in  its  sensible  form,  as  in  the  case  of  a sane  person. 

2.  The  same  thing  may  be  said  of  motor  aphasia,  properly  so- 
called,  produced  by  the  lesion  of  A'  (foot  of  third  left  frontal  con- 
volution) or  of  the  efferent  paths.  Here,  however,  it  should  be 
noted  that  motor  aphasia  often  induces  agraphia  (Lichtheim)  and 
alexia  (Dejerine)— that  is  to  say,  that  at  least  in  some  cases  another 
more  important  section  of  the  mechanism  of  language  and  of  thought 
is  inhibited.  The  loss  is  apparent,  and  is  really  more  serious  when 
the  lesion  extends  also  into  the  white  substance  (subcortical),  in 
which  case  there  disappears,  along  with  the  power  to  write,  every 
other  means  available  to  thought  for  translating  itself  into  symbols 
perceptible  by  others. 

It  is  clear  that,  when  the  thoughts  of  an  aphasic  subject  can  be 

55—2 


868 


PSYCHIATRY 


expressed  in  writing,  it  is  much  easier  to  examine  and  form  a judg-  ! 
ment  of  his  psychic  personality  ; nevertheless,  even  when  the  aphasic  j 
subject  cannot  write,  his  personality  must  not  be  held  to  be  notably  | 
diminished  or  profoundly  disaggregated  if  he  can  understand  those  , 
who  speak  to  him  and  can  express  himself  by  signs.  ; 

Amimia  and  paramimia  are  less  definite  as  regards  their  seat  and  | 
their  signification.  I am  convinced  that  many  of  the  cases  de- 
scribed by  the  old  authors  as  examples  of  amimia  and  paramimia  i 
were  varieties  of  word-deafness,  but  those  associated  with  motor 
aphasia,  whether  word  deafness  is  a concomitant  or  not,  are  always 
the  expression  of  strong  intellectual  decadence. 

3.  Optic  aphasia  presents  various  forms  and  varieties.  There  | 
may  be  simple  abolition  of  the  capacity  to  recognise  wiitten  words, 
though  the  intelligence  is  well  preserved  (simple  alexia).  Those  | 
thus  affected  are  able  to  write,  yet  they  cannot  read  even  what  ^ 
they  themselves  have  written.  In  such  cases  there  is  no  disturb-  | 
ance  either  of  the  formation  or  of  the  proper  manifestation  of  | 

thought.  . , I 

In  another  form  of  optic  aphasia  the  power  of  recognising  | 
objects  as  well  as  written  words  is  lost,  and  the  patients  can  no  j 
longer  distinguish  one  object  from  another.  In  this  case  the  centre  j 
where  images  of  objects  are  registered  is  destroyed,  or  does  not  1 
perform  its  function,  and  hence  the  images  cannot  be  re-evoked  , ,j 
consequently,  the  image  to  be  confronted  with  them  in  the  per-  | 
ceptive  process  is  lacking,  and  this  image  is  necessary  if  there  is  j 
to  be  recognition.  As  is  perfectly  clear,  these  subjects  have  lost  .j 
a part  of  their  mnemonic  capital,  which  is  always  of  great  intellectual 
value.  Sometimes  they  are  confused,  owing  to  their  incapacity  to 
re-evoke  visual  images  of  objects,  persons,  or  occasionally  even  of 
places.  This  form  of  optic  aphasia  always  induces  a grave  dis-  j 
turbance  of  the  psychic  personality,  even  when,  as  frequently 
happens,  it  is  not  associated  with  functional  disturbance  of  the  , 
auditory  centre  of  words,  for  the  simple  reason  that  the  patrimony  | 
of  visual  images  is  very  great  in  every  individual,  and  it  is  through  | 
the  visual  components  that  an  infinity  of  more  complex  thoughts  | 
is  formed  ; and  if  there  are  bilateral  lesions  of  the  occipital  lobes, 
those  thoughts  are  decomposed  and  are  no  longer  representable, 
not  even  by  means  of  their  respective  words. 

Finally,  we  have,  as  already  mentioned,  the  optic  aphasia  of 
so-called  visual  subjects,  the  effects  of  which  on  the  intelligence  are 
analogous  to  those  of  acoustic  aphasia  or  word-deafness.  In  these 
cases  we  must  speak  of  true  aphasic  dementia. 

4.  The  form  of  aphasia  in  which  we  meet  with  the  most  pro- 
found disturbances  of  the  intelligence  is  acoustic  aphasia,  or  word- 
deafness.  Here,  too,  however,  we  must  make  a distinction.  e , 
may  have  subcortical  word-deafness,  due  to  a lesion  of  the  afferent : 
paths,  while  the  integrity  of  the  acoustic  centre  of  language  is  pie- 


AP BASIC  DEMENTIA 


869 


served.  In  this  case  the  individual  is  able  to  read,  and  can  express 
his  thoughts  in  spoken  words,  and  frequently  in  writing  as  well. 
Since  the  centre  of  language  has  been  spared  and  the  register  of 
acoustic  images  of  words  is  unharmed,  and  since  there  is  no  inter- 
ruption of  the  associative  paths  leading  to  and  from  the  kinaes- 
thetic  centre  of  speech  and  the  intellectual  field,  the  other  centres 
also  remain  active  ; the  mechanism  for  the  formation  and  expres- 
sion of  thought  is  therefore  left  in  an  undisturbed  condition.  Con- 
sequently, there  is  either  no  disturbance  of  the  intelligence  or  the 
disturbance  is  such  as  would  not  warrant  us  in  admitting  any 
notable  diminution  or  disaggregation  of  the  psychic  personality. 
The  lesion  in  these  cases  is  found  on  the  afferent  paths  leading  to 
F'  (Fig.  106).  If,  however,  F'  is  destroyed,  and  especially  in  the 
case  of  an  auditory  individual,  the  psychic  personality  is  reduced 
and  altered,  for  the  reasons  already  mentioned.  It  is  in  these 
cases  that  we  find  the  maximum  degree  of  confusion  and  of  mental 
disaggregation. 

5.  Let  us  now  examine  the  other  case,  the  so-called  aphasia 
of  conductivity  or  of  association  (the  Leitungsaphasie  of  Wernicke). 

In  this  case  the  lesion  interrupts  the  associative  paths  F'  A' 
and  hence  the  acoustic  word-images  that  must  pass  over  them  in 
order  to  excite  A'  do  not  reach  this  last  centre,  whose  disordered 
activity  translates  itself  into  a veritable  syllabic  anarchy. 

Two  cases  may  arise*:  either  the  lesion  is  very  much  circum- 
scribed, so  that  it  does  not  affect  the  functions  of  F',  and  as  the  evoca- 
tion of  acoustic  images  is  therefore  normal,  whilst  the  associative 
paths  between  F'  and  C are  not  interrupted,  the  intelligence  is 
preserved  ; but  it  has  difficulty  in  manifesting  itself  in  spoken,  and 
sometimes  even  with  written,  words,  according  to  the  extent  and 
depth  of  the  lesion.  In  this  case  the  individual  hears  and  under- 
stands the  person  who  speaks,  recognises  persons  and  objects,  has 
representations  of  words  (internal  diction),  and  his  thought  is  logi- 
cally developed ; if  he  cannot  read  aloud,  it  is  still  possible  for  him 
to  read  inwardly.  In  any  case,  from  the  very  correct  and  well- 
ordered  conduct  of  the  individual,  from  his  attitude  in  response  to 
the  various  emotions  aroused  by  the  words  of  others,  from  the 
regular  co-ordination  of  his  actions,  from  his  gestures  and  his 
mimicry,  we  can  judge  that  his  intelligence  has  been  preserved  to  a 
very  great  extent,  and  that  the  anomaly  of  thought  does  not  lie  in 
its  formation  or  its  associations,  but  lies  in  the  mechanism  for  the 
expression  of  it.  The  disaggregation  is  only  apparent  ; in  reality 
all  the  constituents  of  thought  exist,  and,  in  regular  association  one 
with  another,  they  furnish  material  for  the  consciousness  to  work 
upon.  Should  the  centre  of  verbal  images  F'  subsequently  become 
paretic  or  interdicted,  owing  to  the  extension  of  the  focus,  the  case 
resembles  that  of  acoustic  aphasia,  with  this  difference,  that  the 
dementia  is  sometimes  temporary  (Bianchi,  II  PolicUnico,  1894). 


CHAPTER  XXXV 


TRAUMATIC  DEMENTIA 

Traumata  on  the  head  produce  widely  differing  results,  sometimes 
really  disastrous.  Here  also  occur  a number  of  circumstances, 
intrinsic  and  extrinsic,  the  value  of  which  cannot  always  be  esti- 
mated. Among  the  intrinsic  circumstances  falls  to  be  noted  the 
different  capacity  to  bear  wounds  that  different  subjects  show  under 
the  same  conditions.  Whilst  relatively  slight  traumata  produce 
grave  consequences  in  certain  individuals,  in  other  cases  traumata 
that  are  violent  and  apparently  grave  have  very  slight  effects. 
Among  the  extrinsic  causes  are  to  be  noted  the  angle  of  incidence 
of  the  trauma  and  the  greater  or  less  elasticity  of  the  cranium,  as 
well  as  the  nature  of  the  trauma  itself. 

As  a matter  of  fact,  in  traumatism  it  is  well  to  distinguish  direct 
action  from  indirect  action,  through  repercussion  on  the  opposite 
parts  of  the  cranium,  where  there  may  be  formed  congestion  ex 
vacuo,  sometimes  with  haemorrhage.  It  is  well  known  that  con- 
gestion and  haemorrhage,  as  well  as  laceration  of  the  nervous  sub- 
stance, are  produced  in  different  parts  of  the  brain,  either  in  the 
direction  of  the  blow  (Duret)  or  at  points  where  the  tissues  have  a 
different  specific  gravity  (Tillmann). 

If  the  question  of  traumata  be  considered  from  this  side,  it 
appears  clear  that  a sharp  instrument  which  strikes  the  cranium 
must  produce  different  effects  from  those  of  a blunt  instrument 
causing  contusion. 

We  must  also  take  into  account  the  state  of  mind,  which  forms  a 
factor  of  great  importance  in  the  constitution  of  the  morbid  picture 
of  traumatic  insanity. 

Here  we  cannot  consider  direct  injuries  to  the  brain,  because 
these  come  under  the  head  of  post-apoplectic  dementia. 

In  general  the  morbid  picture  varies  greatly,  according  to  the 
seat  and  the  gravity  of  the  wound.  In  this  case  also,  as  in  that  of 
destructive  foci,  we  must  note  two  successive  syndromes — the  one 
immediately  following  the  wound,  and  the  other  more  remote, 
wherein  we  have  the  disappearance  of  many  symptoms  of  the  imme- 
diate syndrome  and  the  appearance  of  some  others,  which  we  may 

870 


TRAUMATIC  DEMENTIA 


871 


term  secondary.  Here  I have  nothing  to  add  to  what  I have  already 
said  about  the  symptoms,  which  vary  according  to  the  seat  of  the 
destructive  foci. 

As  to  those  traumata  on  the  head  that  do  not  cause  direct  injury 
to  the  brain,  we  must  make  a distinction  between  such  as  induce 
haemorrhage  or  lacerations  in  the  region  subjected  to  the  blow  or  in 
distant  parts  and  those  in  which  nothing  of  the  sort  happens,  but 
simply  a slow  regressive  change  in  the  nervous  elements,  and  the 
appearance  at  the  same  time  of  a series  of  symptoms  closely  con- 
nected therewith.  In  this  connection  I must  observe  that  the  region 
of  the  cranium  that  is  struck  is  not  without  its  influence.  In  the 
cases  of  some  patients  admitted  to  the  clinique,  and  also  among 
patients  in  the  outdoor  department,  I have  noticed  that  a blow  on 
the  occiput  has  consequences  very  different  from  those  of  a blow  on 
the  frontal  region.  In  the  case  of  one  of  these  patients  a blow  with 
an  axe  on  the  upper  part  of  the  occipital  region,  which  could  not 
have  penetrated,  because  there  was  no  evidence  of  any  lesion  of  the 
occipital  lobe,  had,  however,  brought  about  a clearly  cerebellar 
syndrome,  from  which  the  sufferer  gradually  recovered  during  his  stay 
in  the  clinique  until  he  was  quite  well ; another  patient,  who  had 
been  struck  on  the  front  of  the  head,  for  a long  time  showed  pheno- 
mena of  grave  mental  decadence,  especially  inability  to  evoke, 
superficiality  of  judgment,  with  slowness  of  perception,  incapacity 
to  pay  attention  and  to  work  steadily,  great  affective  excitability, 
and  moody  humour. 

We  are  therefore  justified  in  coming  to  the  conclusion  that  in  a 
certain  number  of  cases  the  symptomatology  of  the  traumatic 
psychoses  is  characterized  by  phenomena  of  deficit  in  the  function 
of  the  part  of  the  brain  underlying  the  seat  of  injury. 

It  is  clear  that  we  cannot  consider  as  traumatic  insanity  all  those 
psychopathies  the  history  of  which  includes  the  action  of  a trauma 
on  the  head,  for  we  often  meet  with  most  diverse  psychopathic 
forms,  in  the  aetiology  of  which  a traumatic  action  figures  merely  as 
a possible  aetiological  factor. 

We  can  take  account  only  of  those  wounds  to  the  brain  the 
symptomatology  of  which  coincides  with  that  of  the  circumscribed 
or  focal  cerebral  lesions  (and  it  is  unnecessary  to  reproduce  in  this 
chapter  the  clinical  pictures  of  these),  or  of  those  psychoses  that 
arise  as  a consequence,  mediate  or  immediate,  of  a trauma,  under 
some  form  or  other,  and  in  a very  insidious  manner.  It  is  our 
intention  to  speak  only  of  traumata  that  act  upon  the  head,  for 
it  would  neither  be  proper  nor  would  it  contribute  to  clearness  in 
dealing  with  this  subject  if  we  considered  all  those  psychoses  that 
arise  subsequently  to  a trauma  on  some  other  part  of  the  body 
(fracture,  dislocation),  or  as  the  result  of  surgical  operations.  In 
these  latter  cases  many  other  causes  co-operate  in  producing  the 
effect — e.g.j  fear,  moral  shock,  chloroform,  etc. 


872 


PSYCHIATRY 


I 


For  the  other  cases,  at  the  utmost  it  may  be  admitted  that  severe 
traumata  on  the  head  induce,  as  a consequence,  a lessened  power  of 
resistance  of  the  brain  to  ordinary  morbigenous  agents.  Thus  only 
can  we  explain  why,  after  a severe  trauma  on  the  head,  an  abscess 
develops  after  a long  interval ; or  why  a form  of  acute  haemorrhagic 
encephalitis  appears  in  individuals  who  had  not  previously  shown 
any  tendency  to  nervous  or  mental  maladies,  and  who  presented 
quite  insignificant  symptoms  immediately  after  the  action  of  the 
trauma.  I advance  the  hypothesis  that,  as  a result  of  traumata  on 
the  head — if  at  all  severe — the  brain  loses  its  phagocytic  or  bio- 
metabolic  power  over  the  toxic  substances  or  the  micro-organisms 
that  are  in  circulation,  and  which  more  readily  affect  an  organ  that 
has  not  the  power  to  destroy  them,  particularly  if  there  is  a heredi- 
tary or  acquired  predisposition  to  the  disease. 

As  a rule,  therefore,  traumata  are  rarely  the  cause  of  immediate 
mental  disorders,  if  we  exclude  those  phenomena  arising  from  cere- 
bral commotion  and  from  lesions  of  the  various  regions  of  the  brain. 
An  exception  to  this  rule  would  be  formed  by  the  case  of  Phelps, 
who  expresses  an  opinion  that  is  not  original,  but  is  still  of  great 
interest  (‘Traumatic  Injuries  of  the  Brain  and  its  Membranes’). 
According  to  this  author,  traumatic  lesions  of  the  frontal  lobes — 
frequently  of  the  left,  not  often  of  the  right  frontal  lobe — are  a cause 
of  grave,  specific,  and  immediate  mental  disturbances.  These  are 
said  to  have  been  present  in  every  case  (aberration  or  deficiency), 
and  were  quite  independent  of  the  stupor.  In  the  subcortical 
variety  of  traumatic  lesions  slowness  and  apathy  predominate, 
while  in  the  cortical  variety  there  is  a predominance  of  errors 
of  memory,  defect  of  attention  and  of  control,  incoherence, 
deliria,  and  stupor,  depending  more  on  the  delirium  and  the 
hallucinations  than  on  poverty  of  ideas.  The  distinction  between 
subcortical  and  cortical  syndromes  is  not  solidly  based  upon 
observation. 

The  symptomatology  is  of  the  most  varied  character.  We  dis- 
tinguish between  those  psychoses  that  develop  immediately  after 
the  cerebral  commotion  (coma  of  greater  or  less  duration)  and  those 
that  have  a more  distant  relation  with  the  trauma,  in  so  far  as  they 
are  developed  at  a late  stage. 

When  the  psychosis  develops  after  the  coma,  it  may  be  separated 
from  it  by  a short  period  of  partial  awakening  of  the  consciousness. 
In  most  cases  we  have  here  a delirium,  more  or  less  intense,  chaotic, 
with  states  of  dreaming,  dysorientation  of  varying  degree,  notable 
dissociation  of  ideas,  extreme  motor  agitation,  and  sometimes  a 
tendency  to  acute  excitement.  This  state  may  last  for  a few  weeks 
or  even  for  two  or  three  months.  The  reintegration  period  then 
commences,  with  slowness  of  ideas,  more  or  less  marked  mnemonic 
lacunae,  incapacity  for  mental  work,  specially  in  arithmetical 
problems,  and  amnesia  of  the  whole  acute  period  of  the  malady. 


TRAUMATIC  DEMENTIA  873 

The  reintegration  may  attain  normal  limits,  but  as  a rule  there 
is  some  deficit. 

In  another  group  of  cases,  and  particularly  in  those  of  individuals 
who  have  hereditary  predisposition,  or  who  have  made  excessive  use 
of  alcohol,  there  may  be  a real  acute  hallucinatory  delirium,  with 
great  agitation,  mental  confusion,  and  dysorientation. 

These  hallucinatory  forms  (traumatic  hallucinosis)  may  be  pro- 
tracted for  a long  period,  or  they  may  give  place  to  states  of  stupor 
with  katatonic  syndromes,  nowise  different  from  those  already 
described  (cases  of  Von  Muralt,  ‘ Katatonische  Krankheitshilder 
nach  Kopfverletzungen,'  Allg.  Zeitschr.  f.  Psych.,  Ivii.). 

Another  variety  of  traumatic  psychosis  is  constituted  by  those 
cases  in  which,  after  more  or  less  profound  coma,  a condition  of 
stupor  continues,  greatly  varying  in  degree  and  duration,  along  with 
slowness  of  thought,  weakness  and  infidelity  of  memory,  and  con- 
fusion, without  delirium  and  without  hallucinations  ; sometimes  we 
can  find,  as  it  were,  only  a duplication  of  the  consciousness.  A 
lady  who  was  under  my  care  presented  a completely  altered  char- 
acter, and  though  she  was  conscious  of  the  external  world  and  was 
in  regular  relations  with  it,  she  showed  herself  irritable  or  merry  to 
an  unusual  degree,  and  frequently  repeated  the  selfsame  things. 
As  a rule,  these  patients  are  extremely  excitable  and  irascible. 
Some  of  them  present  the  phenomenon  of  retrograde  amnesia,  as  in 
the  cases  mentioned  by  me  in  the  chapter  on  memory  (Part  IT). 

There  are  also  found  cases  of  post-traumatic,  agitated  melan- 
cholia, such  as  Huguenin’s  case. 

In  another  group  of  cases  we  find  attacks  of  epileptic  or  of  hys- 
terical character.  In  both  of  these  cases  somatic  phenomena  are 
frequently  present,  but  while  the  attacks  of  epilepsy  bear  the  char- 
acter of  their  organic  origin,  the  others  merely  assume  the  imprint 
of  hysterical  neurosis.  We  shall  speak  hereafter  of  the  epileptic 
variety.  At  present  it  is  of  importance  that  we  should  fix  our  atten- 
tion on  the  hysterical  forms.  Here  I cannot  enter  upon  the  debated 
question  of  the  genesis  and  nature  of  the  traumatic  neurosis  ; still, 
I must  not  neglect  to  call  attention  to  the  hystero-neurasthenic 
character  of  those  subjects  in  whom  we  find  the  prevalence  of  hypo- 
chondriacal manifestations,  concentration  of  thought  on  the  malady 
by  which  they  have  been  seized  and  upon  its  cause,  a tendency  to 
exaggerate  their  own  sufferings,  or  the  more  evident  symptoms  of 
the  malady — an  egoistic  and  egocentric  condition  of  mind,  with  an 
exaggerated  susceptibility  to  suggestion. 

This  condition  of  matters  is  much  more  frequent  and  persistent 
among  us  since  the  passing  of  the  Accident  Law,  which  excites  the 
hope  of  deriving  unexpected  advantages  from  those  accidents  that 
have  been  the  cause  of  the  trouble.  Lawyers  and  doctors  join  in 
perpetuating  a state  of  matters  that  would  otherwise  cease  within 
a very  short  time.  Amongst  others,  I briefly  mention  here  the 


874 


PSYCHIATRY 


case  of  a young  man,  a travelling  postman,  who  was  left  for  some 
hours  in  a stuporous  state  after  receiving  a shock  in  a railway 
collision.  It  was  impossible  to  find  out  whether  he  had  had  hys- 
terical convulsions,  but  on  the  following  day  he  was  found  to  be 
paretic  on  the  left  side.  After  a few  days  the  paralysis  was  com- 
plete, and  later  on  contractures  showed  themselves,  as  in  hemi- 
plegia due  to  a destructive  focus.  The  whole  morbid  picture  was 
contradictory  of  classic  hemiplegia  due  to  a cerebral  focus.  I had 
occasion  to  see  him  some  months  after  the  accident,  when  the  diffi- 
culties of  diagnosis  were  easily  overcome,  and  hysterical  hemi- 
plegia was  recognised.  The  sufferer  presented  all  the  psychic  notes 
of  hysteria  (see  the  chapter  dealing  with  that  subject).  In  the 
meanwhile,  the  hemiplegia  had  persisted  without  variation  for  over 
three  months,  and  by  this  time  legal  action  had  been  taken  against 
the  railway  company  by  him  and  by  others  who  had  received  con- 
tusions in  the  collision.  As  soon  as  the  lawsuit  was  decided  and 
he  had  received  rather  a considerable  sum  of  money,  all  the  symp- 
toms of  the  malady  disappeared  as  if  by  enchantment. 

Traumatic  psychoses  of  late  origin  also  assume  varied  forms. 
The  commonest  of  all,  as  will  be  found  from  an  extensive  list  of 
cases,  is  one  of  the  forms  of  neurasthenia,  which  persists  even 
when  the  subjects  are  completely  freed  from  the  somatic  phenomena 
that  accompanied  the  action  of  the  trauma.  The  sufferers  from  ’ 
this  form  show  a profound  change  in  character,  along  with  cephalalgia 
and  various  painful  sensations  in  the  head,  and  also  vertigo,  which  ; 
is  sometimes  grave.  They  are  in  particular  extremely  irritable,  ' 
and  become  susceptible,  captious,  intolerant,  irascible,  impulsive,  ^ 
extremely  emotional  (explosive  diathesis  of  Kaplan),  sometimes  J 
negligent  in  their  duties,  whilst  at  other  times  they  take  less  interest 
in  their  families,  to  which  they  had  formerly  shown  themselves  most 
attentive.  They  become  cynical,  are  careless  and  indifferent,  and  , 
show  a tendency  to  vagabondage.  Along  with  this  degeneration  ^ 
in  the  affective  and  volitional  spheres  we  find  other  phenomena  j 
of  no  less  importance  in  the  intellectual  sphere.  They  are  less  \ 
capable  of  standing  the  strain  of  intellectual  labour,  their  thoughts  \ 
are  faulty  and  not  so  well  nourished,  their  memory  lacks  fidelity,  i 
their  power  of  attention  is  very  much  depressed,  and  their  imagina- 
tive power  is  poorer.  Frequently  vaso-motor  phenomena  of  great 
importance  coexist  with  the  foregoing  (see  Kopper,  Archiv  /. 
Psych.,  vol.  xxxiii.  ; Guder,  Die  Geistesstor ungen  nach  Kopfverlet- 
zungen,  Jena,  1886). 

]\lania  is  not  rare,  and  most  frequently  it  assumes  the  character 
of  maniacal-depressive  or  circular  insanity.  Another  variety,  also 
frequent,  is  represented  by  the  epileptic  psychosis.  The  epilepsy 
may  form  part  of  the  primary  symptomatic  picture,  or  it  may 
develop  late — months  or  years  after  the  trauma.  The  fits  are 
repeated,  and  are  soon  associated  either  with  the  true  epileptic 


TEA  UMA  TIC  DEMENTIA  875 

psychosis  or  with  the  epileptic  character.  As  a rule,  these  condi- 
tions are  aggravated  by  alcoholism. 

I Cases  of  late  development  of  paranoia,  of  acute  dementia,  of 
j katatonia,  or  of  mental  deterioration,  are  not  wanting. 

In  other  instances  the  emotivity  is  enormously  increased,  and 
the  patients  suffer  from  cephalalgia,  vertigo,  fulness  in  the  head, 
sudden  pallor,  and  also  intolerance  of  alcohol  (traumatic  vaso-motor 
, neurosis  of  F riedmann ) . V ery  frequently  we  find  late  post-traumatic 
! vulnerability  of  the  brain,  whereby  alcohol,  auto-intoxications,  influ- 
enza, and  other  infectious  diseases  find  a favourable  soil  for  the 
development  of  grave  forms  of  psychosis.  Whether  subsequent 
progressive  paralysis  is  to  be  considered  as  a late  cerebropathy  due 
to  the  trauma,  or  whether  the  trauma  should  be  held  to  be  merely 
one  of  the  setiological  coefficients,  is  a matter  that  does  not  seem  to 
us  to  be  as  yet  sufficiently  demonstrated  (see,  however,  Werner, 
‘ Ueher  die  Geisteskrankheiten  nach  Kopfverletzungen,^  Viertelj ahrs- 
schrift  f.  gericht.  Medicin.,  1902  ; Max  Edel,  ‘ Ueber  Unfallspsy- 
chosenP  Psych.  W ochenschrift,  1901). 

Pathological  Anatomy. — Fractures  of  the  skull,  direct  injuries  to 
the  brain,  haemorrhages,  cerebral  abscesses,  and  consecutive  menin- 
gitis cannot  be  discussed  in  this  chapter.  It  must  suffice  to  mention 
them,  and  to  refer  the  reader  to  general  treatises  for  a full  descrip- 
tion. The  more  or  less  extensive  destruction  of  the  cerebral  tissue, 
and  the  consecutive  inflammatory  processes  are  comparable  to 
destructive  foci,  so  far  as  regards  the  functional  deficiency  that 
follows  from  them.  We  have  already  said  something  on  this 
' subject.  Haemorrhage  and  lacerations  produce  secondary  altera- 
tions, cicatrices,  and  inflammatory  residua,  with  or  without  thinning 
of  the  bones  of  the  cranium.  It  is  necessary  to  take  account  of  the 
i swelling  of  the  injured  tissue,  which  immediately  increases  the  endo- 
cranial  pressure.  This  increase  of  pressure  is  not  without  influence 
on  the  subsequent  delicate  alterations  that  occur  in  the  structure 
of  the  nervous  elements  (Walter  B.  Cannon,  American  Journal  of 
Physiology,  vol.  vi.). 

I As  a matter  of  fact,  these  alterations  appear  very  early.  In  an 
experimental  study  Scagliosi  is  reported  to  have  found  the  com- 
mencement of  a degenerative  process  in  the  cells  of  the  glia  seven 
hours  after  the  experiment,  and  in  the  nerve-cells  forty-four-  hours 
afterwards  (‘  Ueher  die  Gehirnerschiitterung  und  die  daraus  im  Gehirn 
und  Riick.  her.  histologischen  V er  under  ungen, Virchow^  s Arch., 
vol.  clii.).  Lutzenberger  found  a polar  distribution  of  the  chromatic 
' substance  in  the  cerebral  cells. 

Such  degenerative  processes  may  be  set  up  in  the  most  varied 
and  distant  parts  of  the  brain,  as  in  one  of  the  cases  of  Adolf  Meyer 
[American  Journal  of  Insanity,  vol.  lx.). 

Whether  the  degenerative  process,  once  it  has  commenced  in 


8;6 


PSYCHIATRY 


the  nervous  tissue,  is  progressive,  and  gives  rise  to  progressive 
paralysis,  or  whether  the  trauma  simply  accelerates  the  degenera- 
tive process  in  a predisposed  brain,  is  a problem  of  which  no  certain 
solution  can  be  given.  Some  observations  of  my  own  might  induce 
belief  in  this  latter  possibility,  although  the  results  are  not  borne 
out  by  more  recent  observations,  such  as  those  of  Kaplan  {Allgem. 
Zeitsch.  /.  Psych.,  vol.  Ivi.),  of  Frost  {American  Journal  of  Insanity, 
1903),  of  Meyer,  and  others. 

According  to  some  (Friedmann,  Kronthal)  the  trauma  occasions 
the  development  of  arterio-sclerosis  and  of  hyaline  degeneration  of 
the  vessels.  These  affirmations  also  are  still  insufficiently  verified. 

There  is  a further  possibility  of  the  development  of  neoplasms 
in  consequence  of  traumata  ; 118  cases  of  neoplasms,  probably  of 
traumatic  origin,  were  collected  by  Alder  {Arch.  f.  Unfallheilkunde, 
vol.  ii.). 

Diagnosis. — The  diagnosis  should  not  present  serious  difficulties. 
Since  the  traumatic  psychosis  does  not  possess  any  special  and 
differential  character,  the  diagnosis  can  be  founded  only  on  the 
history  of  the  trauma.  Such  knowledge,  in  conjunction  with  the 
phenomena  described,  authorizes  us  to  recognise  in  a'^symptomatic 
complexus  the  traumatic  nature  and  origin  of  the  malady.  In 
every  case  we  must  bear  two  facts  in  mind : First,  that  the  trauma 
on  the  head  can  only  increase  the  cerebral  vulnerability,  and  pre- 
dispose to  mental  maladies,  exalting  the  susceptibility  to,  and  the 
intolerance  of,  auto-intoxications  and  hetero-intoxications,  as  well 
as  the  liability  to  infection.  In  this  case  the  post-febrile  psychoses 
(of  influenza,  typhus,  etc.),  or  the  psychosis  due  to  alcoholic  intoxica- 
tion may  preserve  their  own  proper  character  ; Second,  that  the 
percentage  of  psychoses  consequent  upon  traumata  of  the  head  is 
relatively  very  small.  After  the  Franco-Prussian  War,  of  1,785 
men  wounded  in  the  head,  only  13  became  insane.  From 
981  injuries  to  the  head,  collected  by  Stolper,  of  which  138  had 
given  rise  to  very  serious  concussion,  there  resulted  only  12 
cases  of  insanity. 

From  the  medico-legal  point  of  view,  account  must  also  be 
taken  of  the  hereditary  predisposition  and  of  alcoholic  habits,  as 
well  as  of  the  antecedent  character  of  the  persons  sustaining  traumata. 

Some  time  ago  I had  to  express  an  opinion  as  to  the  origin 
of  an  epilepsy  that  had  developed  in  a woman  who,  when  travelling 
by  railway,  suffered  an  injury  to  the  head,  owing  to  the  very  sudden 
stoppage  of  the  train.  She  showed  slight  contusions,  with  ecchy- 
mosis  on  the  supra-orbital  region,  but  without  wounds  or  fracture. 
Inquiries  into  her  family  history  clearly  proved  the  pre-existence 
of  a character  excitable,  impulsive,  irascible,  and  aggressive  to  an 
extreme  degree.  In  such  a case,  from  the  psychic  character,  the 
latency  of  epilepsy  was  very  evident. 


TRAUMATIC  DEMENTIA  877 

The  shock,  which  cannot  have  been  very  severe,  simply  removed 
the  last  slight  obstacle  to  the  outbreak  of  the  convulsions. 

Prognosis. — The  prognosis  is  rather  grave,  especially  if  there  are 
somatic  phenomena  dependent  on  lacerations,  haemorrhage,  loss  of 
blood,  secondary  inflammation,  etc. 

In  these  cases,  on  recovery  from  the  acute  form  that  develops 
after  the  immediate  effects  of  the  trauma  (coma,  epilepsy,  deliria, 
stupor),  it  is  highly  probable  that  a mental  deficiency  will  remain. 

Grave  also  is  the  prognosis  of  the  late  psychoses  of  degenerative 
type  (epilepsy,  immorality,  impulsiveness). 

Much  less  grave  are  the  hysterical  and  neurasthenic  forms, 
which,  however,  are  sometimes  indefinitely  prolonged,  especially 
when  medico-legal  decisions  are  involved.  In  those  other  primary 
or  secondary  psychoses  that  depend  upon  an  intoxication  due  to 
the  increased  vulnerability  of  the  cerebrum,  the  prognosis  must  be 
guided  by  general  principles,  at  the  same  time  taking  into  account 
the  special  features  of  each  case. 

Therapy. — The  therapy  includes  various  methods  and  resources. 
The  comatose  states  are  treated  by  cardiac  stimulants,  blood- 
letting, intestinal  depletions,  etc.,  according  as  there  are  present 
signs  of  collapse  or  of  increased  endocranial  pressure.  The  con- 
secutive inflammatory  processes  are  to  be  treated  on  general  lines. 
For  the  rest,  the  treatment  can  only  be  symptomatic.  Deliria, 
hallucinations,  psycho-motor  agitation,  epilepsy,  and  katatonia  are 
treated  on  the  lines  laid  down  in  the  respective  chapters. 

The  hysterical  syndromes  are  aggravated,  as  already  mentioned, 
by  the  influence  of  legal  proceedings. 

Surgical  intervention  is  often  called  for,  either  by  the  existence 
of  bony  depressions  or  when  there  are  evident  signs  of  a circum- 
scribed cortical  or  subcortical  lesion,  irritant  or  paralyzing,  even 
although  the  conditions  are  not  complicated  by  any  fracture  or 
depression  of  the  cranial  bones.  The  site  for  trephining  will  be 
indicated  by  the  nature  of  the  symptoms,  which  may  be  referred 
to  a particular  cerebral  region.  The  reviews  of  surgery  and  neuro- 
pathology contain  a large  number  of  records  of  trephinings  per- 
formed in  cases  of  injuries  to  the  head. 

Trephining  is  also  indicated  in  the  reflex  neuroses  and  psychoses 
resulting  from  injury.  Several  years  ago  I had  occasion  to  publish 
details  of  an  interesting  case  of  this  kind  (Bianchi,  ‘ Contributo 
alia  terapia  chirurgica  delV  epilessiaP  Annali  di  Nearologia,  1891). 


INDEX  OF  AUTHORS 


Abbatucci,  205 
Abit,  294 
Abricossoff,  541 
Achalme,  5 1 
Achard,  837 
Adamkiewicz,  240 

Agostini,  456,  462,  523,  524,  672,  681, 

783 

Albertoni,  58,  506 
Alder,  876 
Alessi,  522,  758 
Algeri,  64,  198 
Allegri,  245 
Allen  Starr,  130 
Allin,  179 

Alzheimer,  528,  695 

Amadeo,  74S.  784 

Ameline,  820 

Anastay,  307 

Anderson,  183 

Andriani,  439 

Andriezen,  96,  772 

Angiolella,  336,  409,  484 

Anglade,  683,  757 

Anjel  278.  653 

Anngell,  359 

Antonelli,  175 

Antonini,  440,  761 

Apaty,  14,  32,  86,  89,  90,  91,  315 

Arnand,  327,  820 

Arndt,  340,  470,  622 

Arnold,  71 

Arsonval,  406 

Aschaffenburg,  306,  312,  315,  336 

Ascher,  807 

Ashley,  182 

Atwater,  764 

Auerbach,  192 

Awtowkratow,  812,  816 

Axenfeld,  659 


B 

Babes,  762 

Baccelli,  45,  47,  830 

Baer,  484,  499,  768 

Baginsky,  45,  47 

Baillarger,  800,  822,  828 

Bain,  180,  228,  241,  261,  307,  309 

Baldwin,  231,  255,  353,  354 


Ball,  331,  681 

Ballet,  130,  141,  327,  336,  624,  757, 
822,  825 
Balzer,  836 
Bang,  768 
Barba,  45 
Barbato,  695 
Bartels,  231 
Basedow,  354 

Bastian,  130,  136,  147,  226,  231 

Bauer,  843 

Beard,  238,  653,  659 

Beatley,  805 

Beaunis,  7 

Bechterew,  45,  46,  47,  53,  55,  57,  66, 
99,  100,  III,  114,  122,  123,  124,  123, 
188,  370,  371,  375,  SOI,  517,  53i, 
809 

Bedard,  221 
Beliakoff,  527 
Bellisari,  518 
Belmondo,  762 

Benedikt,  410,  450,  483,  526,  764 

Bennet,  814 

Berghinz,  455 

Bergonzoli,  683 

Bergson,  363 

Bergstrom,  31 1 

Berillon,  630 

Berkeley,  190,  420,  753,  770,  772,  864 
Bernard,  130,  340 
Bernard  I.eroy,  279 
Bernardini,  265 
Besta,  523,  761 
Bethe,  13,  89,  90,  95 
Bevan  Lewis,  81,  816 
Bianchi,  66,  99,  148,  287,  305,  310,  336, 
408,  455,  458,  463,  477-  499.  505.  534. 
540,  578,  596,  652,  657,  661,  669,  692, 
758,  802,  806,  813,  852,  869,  877 
Bidon,  221 
Bielchowsky,  56 
Biernacke,  658 
Biewliet,  92,  203,  241,  279 
Binet,  201,  203,  233,  234,  245,  255,  256, 
265.  312,  359,  540,  668 
Binswanger,  576,  655,  658,  659,  826 
Binz,  764,  766 
I Birch,  231 
Bircher,  468 
I Bischotf,  10 
I Blanchard,  7 
879 


88o 


INDEX  OF  AUTHORS 


Bleuler,  527,  769 
Bloch,  188 

Blocq,  427,  653,  658,  659 

Bochefontaine,  122,  124,  125,  371 

Bodlander,  764 

Bodicker,  804 

Bodoni,  531 

Boll,  81 

Bolton,  185,  255 
Bombila,  831,  832 
Bordoni-tJhreduzzi,  761 
Borosdin,  527 
Borowkoff,  516 
Bouchard,  821,  853 
Bouchut,  653 

Bourdon,  178,  179,  182,  188,  190,  243, 
245,  256,  279,  307 

Bourneville,  435,  437,  438,  456,  460,  463 
Bouveret,  653,  659 
Boyer,  58,  158,  159 
Bra,  523 

Bradley,  302,  348 
Bramwell  Milne,  645 
Brasch,  836 
Bratz,  523 
Brentano,  313 
Brequet,  712 
Breuer,  638 
Briand,  820 
Bridier,  846 
Brigatti,  58 

Brissaud,  40,  42,  43,  44,  48,  52,  88,  102, 
370,  371,  456,  822,  837,  843,  853 
Bristowe,  820 
Broadbent,  129,  130,  149 
Broca,  10,  33,  34,  73,  79,  144,  360,  810 
Brown-Sequard,  62,  109,  269 
Bruce,  54 
Brugia,  524 
Brunet,  829 
Brusch,  824 

Buccola,  192,  193,  231,  232,  407,432,  809 

Buchholtz,  753,  757 

Bucke,  303 

Bukley,  825 

Burdach,  51,  73,  814 

Butzelsky,  812,  816 

Byrom  Bramwell,  50 


C 

Cabitto,  758 
Cacqueur,  45 

Cajal,  14,  32,  39,  45,  48,  49,  70,  81,  82, 
84,  85,  86,  90^  96,  1 18,  156,  812,  846 
Calkins,  307,  347,  351,  353 
Calmeil,  436,  755 
Calori,  10 
Camuset,  272,  330 
Cannon,  875 

Cantani,  228,  455,  463,  863 

Cantarano,  668 

Capobianco,  89,  90,  96,  468 

Cappelletti,  659,  758 

Capriati,  809 

Carbini,  818 

Carito,  659 

Carle,  468 

Caro,  524 

Carpenter,  227 

Carrara,  410,  483 


1 Carthy,  519 
Castin,  331 
Castronuovo,  32 
Catsaras,  639 
Cattel,  191 

Ceni,  462,  523,  524,  525,  532,  670,  67ii 
I 758,  761,  762 
I Chaddock,  668 
Chalmers,  779 

Charcot,  65,  130,  132,  135,  144,  205,  342, 
539,  636,  658,  667,  793,  853 
Charpentier,  820 

Chaslin,  336,  427,  527,  71 1,  712,  730, 

737.  738 

Chauveau,  764 
Chevalier,  524 
Chiossi,  807 
Chouppe,  524 

Christian,  503,  523,  725,  757,  796,  820, 
831 

Church,  623 

Clark,  522 

Claude,  499 

Clouston,  420,  712,  752 

Cohn,  245 

Colajanni,  479,  765 

Colegrowe,  260 

Colella,  275,  741,  772,  816 

Colleja,  84 

Collier,  457 

Colman,  421 

Colucci,  41,  45,  90,  95,  96,  105,  505,  527, 
735,  786,  846 
Commange,  500 
Connolly  Norman,  713 
Cook,  233 
Coppin,  757 
Corrado,  94 
Costa,  779,  832 
Cotard,  328,  331 
Courtier,  233,  359 
Co  wen,  97 
Cramer,  572 

Cristiani,  125,  468,  523,  818 
Cullerre,  336,  808,  818,  825 
Curtius,  302 
Cyon,  170 

D 

D’  Abundo,  62,  64,  95,  205,  269,  459,  $24, 
672,  814,  815,  816 
Dagonet,  439,  71 1,  738,  81 1,  812 
D’  Agostini,  420 
Dallemagne,  623 
Dally,  539 
Dalmar,  822 
Dana,  58 
Dandola,  407 
Danilewsky,  4,  121 
Danillo,  100 
Darkschewitsch,  42 
Darlington,  232 
I Darwin,  6,  300,  410,  471 
D’  Ascoli,  302 
! D’  Astros,  459 
I Daub,  764 
' Davies,  831 
Dearbon,  312,  3159,  407 
De  Boni,  505 
Deliio,  772 
Deiters,  46 


INDEX  OF  AUTHORS 


88i 


^ Dejerme,  27,  34,  40,  43,  49.  52,  56,  58, 
|,  65,  67,  69,  73,  77,  78,  102,  144,  158, 

! 161,  762,  814,  867 

Delasiauve,  782 
Delboeuf,  191,  241 

Del  Greco,  324,  326,  571,  575,  712,  728 
. Dell’  Isola,  92 
Demoor,  93 
Deny,  524 
Dercum,  526 
De  Renzi,  750,  827 

De  Sanctis,  183,  213,  226,  232,  309,  329, 
420,  463,  492,  616,  635 
Descartes,  358 
Despine,  475 
Devay,  822 
Devouges,  782 
De  Watteville,  130 
Dewey,  353,  354,  355 
Didi,  524 
Diedsens,  278 
Dietze,  186 
Dinkier,  824 
Dixon,  188 
Donaggio,  462 
Donaldson,  10,  ii 
Donath,  519 
D’  Ormea,  722 
Dostojewski,  488,  491 
Dotto,  505 
Doutrebente,  828 
Dresslar,  183,  203 
Dril,  487,  498 
Drobisch,  265 
Dubois-Raymond,  484 
Duclaux,  764 
Dugas,  278,  279,  373 
Dujardin,  8 

■ Dumas,  309,  360,  366,  367 
Dumont,  2,  366 
Duneschi,  124 
Dupre,  843 
Duret,  870 
Duval,  17 1,  314 

E 

; Ebbinghaus,  193,  221,  244,  255,  263, 

, 265,  499 

I Ebert,  417 
I Eckener,  233 
I Ecker,  147 

I Edinger,  27,  29.  36,  52,  53,  55,  81 
! Eggli,  178 
„ Eisenlohr,  824 
Elzholz,  772 
^ Emerson,  302 

I Emminghaus,  434,  435,  437,  438 
Engelmann,  6,  12 
I Erlenmeyer,  777,  779 
Erlsberg,  176 
I Esposito,  741 
■■  Eulenburg,  125 
Ewald,  824 
Exner,  192 


Fabre,  828 

Falret,  333,  639,  642.  807,  829 
Fano,  170 
Faucault,  182 


j Fechner,  192,  193,  221,  228,  229 
Feketin,  499 

! Fere,  213, '221,  234,  346,  352,  374,  377, 
j . 422,  463,  49F  505.  509.  524,  526,  527, 
555,  623,  639 
Ferner,  836 
Ferranini,  523 

Ferrari,  244,  265,  372,  377,  402,  435,  539 
Ferrati,  761 

Ferrero,  355,  473,  491,  497,  663 
Ferri,  476,  768 

Ferrier,  37,  43,  55,  56,  58,  99,  loi,  109, 
III,  112,  113,  230,  458,  526 
Fick,  181 
Finzi,  728 
Fischer,  527 
Flaiani,  681 
Flechner,  36 

Flechsig,  36,  45,  46,  47,  48,  51,  52,  54, 
56,  58,  69,  85,  no,  130,  132,  143,  149, 
150,  151,  152,  153,  154,  155,  156,  157, 
158,  159,  161,  162,  168,  173,  350,  351, 

370,  531 

Flemming,  90,  91 
Flourent,  103,  178 
Foerster,  104 
Foinitsky,  501 
Folsom,  825 

Forel,  5,  13;  72,  76,  279,  473,  678 
Fornario,  814 
Fouillee,  279 
Foulis,  148 

Fournier,  562,  754,  817,  835,  837 
Foville,  588 
Fox,  762 

Fraenkel,  806,  810 

Fragnito,  89,  90,  92,  96,  459,  846 

Francotte,  336,  523,  630,  647 

Frank,  in,  122,  359 

Freud,  310,  373,  623,  627,  638 

Freund,  144 

Frey,  349,  806 

Friedliinder,  528 

Friedmann,  324,  326,  815,  875,  876 
Friedreich,  455,  623 
Friis,  772 
Frise,  832 

Fritsch,  L09,  711,  712,  737 
Fronda,  806 
Frost,  876 

Fiirstner,  100,  523,  712,  755,  772 
Funaioli,  819 
Funke,  346 
Futterer,  757 


G 

Gaffky,  417 
Gagnani,  45 
Gajkiewicz,  836 
Galante,  698,  807 
Galiano,  753 
Galton,  245 
Ganbault,  51 
Ganel,  505 
Gannouchkine,  674 
Ganser,  36 
Gazel,  836 
Gee,  56 
Geill,  801 
Geppert,  764 
Gerdes,  816 


882 


INDEX  OF  AUTHORS 


Gerlach,  86 

Giacomini,  460,  461,  462 
Giaglinski,  349 
Gieson,  95 

Gilles  de  la  Tourette,  658 
Gilmann,  345,  346 
Girma,  831 
Girondon,  325 
Gley,  233,  668 
Goldflarnni,  836 
Goldscheider,  190,  350 
Golgi,  14,  32,  49,  51,  81,  83,  86,  87,  89, 
90,  95,  96,  III,  118,  757,  811 
Goltz,  loi,  102,  1 19,  170,  178 
Gomperz,  304,  305 
Gonzales,  522,  527 
Gosio,  761 

Gowers,  50,  51,  52,  54,  59,  81,  370,  526, 
827,  853 
Graber,  5 
Grasset,  130 
Grassi,  32 

Gratiolet,  78,  102,  107,  143,  147 
Green,  519 

Greidenberg,  817,  819,  823 

Greifi,  81 1 

Greiwe,  56 

Greppin,  813,  815 

Griesinger,  266,  435,  575 

Grigorieff,  768 

Grimaldi,  571,  827 

Grimm,  302 

Grutzner,  203 

Gncci,  474 

Guder,  874 

Gudden,  36,  40,  41,  42,  47,  101 

Guerin,  525 

Guggenbuhl,  436 

Guicciardi,  198,  244,  539,  616 

Guillemet,  768 

Guillon,  264,  266 

Guislain,  402,  540 

Gurney,  207 

Gutch,  52 

Guyon,  364 

H 

Haacke,  176 
Habershon,  145 
Hadden,  50 
Hadies,  832 
Haeckel,  176 
Hahn,  302 

Haidenhain,  171,  238 
Haig,  523,  524 
Hale,  302 

Hammarberg,  ii,  80,  84,  156,  251 

Hamilton,  225 

Hammond,  651 

Hans  Kami,  62 3 

Han  way,  471 

Hargreaves,  769 

Harris,  562 

Hartenberg,  373,  374,  379,  630,  647 

Hartley,  309 

Havelock  Ellis,  667,  668 

Hawchins,  244 

Hecker,  623 

Heger,  4 

Heinke,  91 

Heinrich,  233 


Heinroth,  435 
Held,  14,  89,  90,  91 
Helmholtz,  221,  227,  464 
Henger,  824 

Henry,  191,  255,  256,  312 
Henschen,  36,  40,  43,  44,  45,  58,  102, 
104,  105,  248 

Herbart,  180,  239,  241,  255 
Hering,  240 

Hermanides,  816,  835,  837 

Hermann,  346 

Herter,  523,  525 

Her  twig,  7 

Hess,  1 81 

Heubach,  764 

Heymans,  201 

Higier,  221 

Hillebrand,  182,  188 

Hinrichsen,  675 

Hipp,  191,  406 

Hirsch,  500,  818 

Hirth,  296 

His,  48,  86 

Hitzig,  85,  99,  100,  109,  no.  III,  1 12, 
125,  156,  157,  159,  506,  699,  750,  823 
Hobes,  345 
Hoche,  51,  757,  814 
Hodge,  94 

Hosel,  54,  56,  57,  no 

Hofding,  180,  256,  307,  348 

Hollander,  695 

Holmgreen,  95 

Holsti,  757 

Hoppenheimer,  348 

Horsley,  52,  100,  112,  114,  468 

Horwicz,  227 

Howe,  307, 

Huebner,  833 
Huguenin,  873 
Hugues,  796,  825 
Hun,  104 
Huntingdon,  750 
Huschard,  653 
Huxley,  n 

I 

Idanow,  823 
Ingenieros,  476 

Ireland,  265,  430,  435,  439,  444,  457. 
560 

Irons,  353,  354 
Iscovesco,  644 

J 

Jackson,  147,  276,  479,  506 
Jacobs,  245,  255 
Jahrmarker,  728 
Jakimow,  772 

James,  2,  169,  177,  180,  186,  187,  190, 
193,  200.  221,  224.  263,  305,  311,  353, 
354,  355,  359,  360,  361,  363.  372,  393, 

471 

Jandrintzefl,  488 

Janet,  216,  232,  238,  364,  367,  398,  533, 
534,  538,  540,  562,  638,  645 
J astro  vitz,  818 
Jastrow,  255 
Jendrassick,  832 
Jensen,  755 

I Johrov,  221,  555,  820 
I Jolly,  364,  484,  537,  685 


INDEX  OF  AUTHORS 


883 


li  ■ K 

I Kaes,  694 
I Kahlbaum,  522 

I Kalin,  463 
Kalzowski,  758 

: . Kant,  288,  313,  345 
Kaplan,  874,  876 

II  Keester,  524 

j:  Kesteven,  457 

I Kethi,  123 
Kiernan,  668 
? Kind,  463 
! Kinsburg,  527 

' Kirctihoff,  351,  713 

i Kirkpatrick,  243,  255 
I Kirn,  622 

Kirschmann,  181,  188,  194 

Kitchener,  351 

Klebs,  458,  468,  824,  832 

Knapp,  58 

Knies,  100 

Knox,  201 

Knudt,  818,  819 

Kocher,  532 

Kolliker,  32,  48,  49,  50,  70,  81,  84,  156, 

314,  315.  370 

Konig,  181,  194,  794 
Konrad,  71 1 
Koppen,  519 
Kopper,  874 
Korsakoff,  275,  741 
Kossowictz,  764 

' Kowalewski,  264,  413,  476,  484,  489, 

491.  497.  499.  501.  532,  753.  818, 
837 

Kraeplm,  279,  306,  423,  640,  642,  673, 
678,  685,  686,  696,  697,  704,  71 1,  712, 
725,  728,  769,  851 

Kraft-Ebing,  336.  523,  558,  571,  575, 
622,  640,  667,  681,  71 1,  712,  737,  823, 
826 

Krainsky,  523 
' Krause,  61 
I Kries,  182,  188,  192 
' Krishaber,  653 
I Kronthal,  813,  876 
I Krukenberg,  772 
' Kuh,  824 

Kiilpe,  181,  256,  347,  348,  353 
Kundrat,  458 
Knssmaul,  130,  147,  300 


I. 

i Lailler,  806 
Lalande,  278 
: Lambert,  94 

Lambiasi,  532 
Lambranzi,  436 
Larny,  221,  843 
I Lanciois,  50,  170,  349 
Landon  Dowen,  457 

Lange,  226,  227,  230,  231,  233,  352,  353, 
354.  355.  359.  360,  367,  372 
- Lannegrace,  100 
, Lannois,  582 

Lasegue,  333.409,  5^8,  537,  538,  588,  828 

Lauder  Brunton,  170 

Laugenhagen,  <31 

Laupts,  667 

Laurent,  491,  664 


Le  Bon,  396 
I.ecorche,  518 
Legrain,  525,  624,  642 
Legrand  de  Saulle,  364,  509,  518,  537, 
634,  828 

I.ehmann,  233,  256,  31 1,  352 

Leloyer,  675 

Lelut,  310 

Lemesle,  31 1 

Lemoine,  526,  831 

Lemos,  205 

Lenhossek,  69,  86,  90,  92 

Lennan,  359 

Lenzi,  805 

Leopardi,  472 

I.epine,  124,  314 

Leredde,  831 

Leube,  653 

Leubuscher,  531,  681,  806 
Levi,  90,  471 
Levillain,  659 
Lewes,  228,  363 
Libertini,  170 
Tdchtheim,  15,  130 
Liebmann,  812 
Liepmann,  772 
Linossier,  653 
Lissauer,  813 

Little,  70,  454,  461,  463,  519 
Ljubimow,  527 
Lloyd,  52 
Locke,  305 
Lockhart-Clarke,  81 1 
Loeb,  100 
Loffler,  824,  832 
Lowenthal,  49 
Lojacono,  336,  576 

Lombroso,  208,  375,  381,  409,  410,  467, 
468,  473,  476,  480,  483,  484,  488,  491, 
497.  500,  501,  505,  509,  510,  5 1 1,  518, 
526,  529,  573,  667,  761,  767,  822 
Lombros,  Paola,  300,  302 
Long,  56,  58 
Lorain,  457 
Lowes,  824 
Lubbock,  13 
Lubimow,  81 1,  816 
Luchsinger,  17 1 

Luciani,  57,  99,  100,  loi,  iii,  112,  114, 
121,  159,  506 
Luckey,  181,  350 
Ludwig,  50 

Lugaro,  91,  94,  188,  734,  782 

Lui,  523,  524,  526,  765,  819 

Lussana,  178,  205 

Imstig,  468 

Lutzenberger,  712 

Lays,  215,  240,  816 

Luyt,  664 

Lydston,  668 

Lyer,  202 


M 

MacDougal,  233 
Macpherson,  825 
Madia,  730 

Maffei,  434,  435,  437,  438 
Maffucci,  422,  462,  670 
Magalhaes,  Lemos,  692 
Magendi,  36 
Maggi,  176 


56—2 


884 


INDEX  OF  AUTHORS 


Maggiotto,  722 

Magnan,  353,  573,  576,  624,  636,  642, 
667,  668,  734,  766,  769,  772,  778,  809, 
811 

Mahaim,  56,  812 
Mairet,  524,  821 
Malapert,  471 
Mandalari,  728 
Mann,  94,  124,  349,  769 
Mantegazza,  166,  213,  359,  380,  381,  432, 
667 

Maragliano,  288,  455,  463,  863 
Marambat,  768 

Maraud  on  di  Montyel,  337,  827.  829 
Marc,  436 
Marce,  752 
Marchand,  822 

March!,  63,  64,  65,  70,  75,  77,  527 
Marie,  331 
Marimd,  852 

Marinesco,  91,  97,  523,  524,  527,  528,  824, 
846 

Marro,  408,  4^0,  483,  500,  694,  806, 
832 

Marschalko,  812 
Marshall,  347,  348 
Martinotti,  81,  463,  526 
Maschka,  590 
Masini,  61 

Massalongo,  455,  523 
Masse! , 61 
Mathieu,  659 
Matt!  Helenius,  768 
Maudsley,  227,  240,  412 
Max  Edel,  875 

Max  Muller,  298,  299,  302,  303,  304,  305, 

857 

Max  Simon,  213 
Max  Verworn,  5 
Mayer,  56 
Mead,  345 
Mehner,  186 
Meilhon,  824 
Mele,  518,  562 

Mendel,  338,  419.  558,  575,  681,  753,  755> 
811,  813,  815,  816,  818,  819,  827 
Mendelsohn,  556 
Mendoza,  205 

Mercier,  353,  388,  393,  839 
Meschede,  813 
Meumann,  184,  185 
Mey,  45 

Meyer,  121,  875,  876 
Mevnert,  ii,  36,  40,  41,  56,  74,  81,  155, 
340,  346,  352,  370,  527,  571,  575.  576, 
640,  655,  711,  712,  737,  811 
Mezes,  346 
Mickle,  642,  754,  815 
Milhaud,  188 
Mill,  180,  224,  309,  864 
Miller,  346 

Mingazzini,  69,  370,  371,  462,  526,  853 

Minor,  818 

Mirallie,  144,  158 

Mirto,  205,  463,  524,  639,  683 

Mirzejewski,  772,  81 1,  816 

Mislawski,  122,  123,  124,  371 

Mitchell,  205,  659 

Mobille,  334 

Moebius,  658,  822 

Moeli,  804 

Moll,  664,  667 


Monakow,  41,  46,  47,  54,  55,  56,  57,  58, 
85,  100,  102,  104,  105,  159,  371,  816, 
827 

Mondio,  457,  463,  786 
Monti,  761 

Moreau  de  Tours,  440 
Morel,  413,  439,  539,  623,  626,  627,  639, 
829 

Morselli,  191,  192,  198,  238,  242,  375, 
408,  420,  492,  518,  622,  638,  640,  641, 
642,  712 

Morton  Prince,  667,  669 

Mosso,  124,  234,  367,  407 

Mott,  48,  52,  55 

Moury,  213,  264,  282 

Mueller,  38,  185,  202,  255,  302,  31 1 

Miinger,  55 

Munk,  43,  44,  56,  99,  100,  loi,  103,  104, 
105,  no.  III,  112,  114,  121,  171,  248, 
371,  468,  773 

Munsterberg,  179,  186,  188,  190,  229, 
231,  233,  244,  255,  307,  352,  359,  406 
Muralt,  873 
Muriac,  836 

N 

Naecke,  484,  772,  820 
Naunyn,  750 
Neisser,  738 
Neumann,  764 
Nichols,  349,  350 
Nicolucci,  147 

Nissl,  14,  90,  91,  93,  94,  95.  735^  772,  786 

Nitti,  499 

Noera,  712 

Norman  Henry,  516 

Nothnagel,  370,  523 


O 

Obersteiner,  34,  37,  40,  42,  81,  231,  8i& 

Obici,  328 

Oddi,  170,  17 1 

Ogle,  36,  i47>  148 

Ohlmacher,  526 

Olliver,  804 

Onufrowicz,  45,  46,  47,  76,  462 
Oppenheim,  371,  824 
Orchanscky,  713 
Orfanoff,  488 
Orr,  97,  683,  814 
Ostankow,  122,  123,  371 
Ottolenghi,  484,  486,  523.  526 


P 

Pace,  374 
Pal,  66,  71,  827 
Paladino,  89,  90,  96 
Palmer,  566 
Paneth,  255 
Panizza,  loi 
Pardo,  247 
Parrisch,  191 
Patini,  562,  563,  730 
Patou,  695 

Patrizi,  231,  407,  489 
Paulham,  309,  366 
Peacock,  10 
Pellacani,  124 


INDEX  OF  AUTHORS 


885 


Pellegrini,  524,  590 
Pellizi,  460,  761 
Pennato,  455 

Penta,  410,  476,  483,  500,  501,  666,  667, 
668,  830 
Pergens,  93 
Perinaud,  793 
Per  on,  525 
Petersen,  851 
Peterson,  817 
Petrine,  1 1 7 
Phelps,  872 
Philippe,  51,  205,  243 
Pianese,  750 
Pianetta,  523,  767,  822 
Pic,  843 

Piccinino,  758,  806 
Piccolomini,  814 
Pichon,  336 
Pick,  234,  279,  813 
Pierce,  188 
Pieri,  522 
Pierret,  846 
Pilcz,  699 
Pilliet,  457 
Pini,  532 
Piper,  463 

Pitres,  68,  130,  132,  146,  158,  159,  205, 
353.  357.  375.  546,  555.  623,  624,  626, 
630,  636,  637,  639,  642 
Poincare,  814 
Popof,  36 
Pottes,  758 
Pouchet,  12 
Pravaz,  632 

Preobraschensky,  122,  146 
Preyer,  300,  301 
Prinke,  96 
Pritchard,  831 
Prouvost,  334 


Q 

Quensel,  52 


R 

Rabe,  843 
Rabl-Riickard,  314 
Raggi,  483,  683 
Ransome,  36 
Ranvier,  95 
Rasori,  758 
Ranh,  363,  364 
Raymond,  52 
Redlich,  804 

Regis,  214,  336,  353,  357,  375,  555,  577, 
623,  626,  630,  636,  637,  639,  642,  672, 
681,  757,  782,  818,  822,  832,  844 
Reid,  10 
Reineke,  766 
Rene  Semelaigne,  353 
Repping,  683 
Retzius,  32,  37,  45,  49 
Rend,  676 
Reverchon,  843 

Ribot,  224,  227,  241,  246,  247,  248,  258, 
260,  261,  265,  279,  280,  282,  346,  347, 
381,  624 

Richet,  192,  238,  240,  241,  249,  261,  263, 

347.  349.  359. 


Riegler,  630 

Ritti,  331,  844 

Riva,  572,  576,  809,  810 

Rivano,  806 

Rizet,  205 

Robertson,  672,  735,  81 1,  815,  824,  832 

Robinovitch,  413,  523,  575,  765,  769 

Robinson,  182,  676 

Rochefoucaud,  661 

Rockwell,  659,  698 

Rosch,  438 

Romanes,  5,  305,  857,  864 
Romberg,  370 

Roncoroni,  484,  505,  526,  532,  697 

Rosenbach,  371,  506 

Rosenstein,  527 

Rosenthal,  653 

Ross,  130,  522 

Rossi,  328,  532 

Rothmann,  68 

Rouillard,  644 

Roux,  224 

Rows,  814 

Rummo,  45 

Russel,  50 

Rutishauser,  69 


S 

Sacconi,  37 
Sachs,  79,  104,  685 
Sadun,  522 
Sala,  96,  532 
Salemi,  374 
Salgo,  519,  523 
Samt,  767 
Sander,  270,  577 

Sanna  Salaris,  478,  697,  814,  823 
Sauze,  739 
Scagliosi,  875 

Schafer,  37,  52,  57,  83,  99,  100,  102,  103, 
1 12,  642,  816 
Schaffrot,  499 
Schaw,  58,  832 
Schiattarella,  208 
Schieberck,  825 

Schiff,  50,  109,  no,  III,  1 14,  170,  178 

Schlapp,  84,  156 

Schlegel,  302 

Schleicher,  302 

Schlesinger,  56 

Schneider,  37,  238 

Schnopfhagen,  72,  74 

Schopenhauer,  345 

Schotze,  681 

Schrenck-Notzing,  667,  668 

Schiile,  360,  420,  537,  558,  575,  623,  640, 

711,  712,  713,  755,  757,  826,  828 
Schuller,  125 

Schultze,  32,  54,  300,  301,  531,  683 
Schumann,  185,  255 
Schutz,  814 
Schwalbe,  81 

Sciamanna,  321,  433,  576 
I Scripture,  255,  305,  307 
Seashore,  202 

Seglas,  328,  330,  575,  623,  639,  642,  692, 

712,  730,  737,  739 
Seguin,  147 

Selmi,  806 
Senise,  558 


886 


INDEX  OF  AUTHORS 


Seppilli,  loo,  III,  1 17,  148,  214,  455,  463, 
506,  523,  527,  694,  728,  745,  761,  765. 
805,  809,  819 
Serbsky,  712,  728 

Sergi,  241,  248,  249,  353,  360,  410.  478 

Serieux,  325,  524,  527 

Seyiert,  179 

Seylus,  728 

Sgobbo,  439 

Sgrosso,  804 

Sherrington,  50,  124 

Sidney,  346 

Siemerling,  156,  804,  823 

Sighele,  375 

Sikorsky,  301,  360 

Simon,  359 

Singer,  55 

Sion,  762 

Smith,  242,  245,  307,  531 
Snell,  757 
Solder,  52 

Sollier,  132,  142,  248,  249,  250,  251,  253, 
265,  435,  438,  533 
Sommer,  527 
Sormani,  671 
Sottas,  49 
Soukhanoff,  674 

Soury,  4,  5,  70,  104,  279,  314,  348,  350, 
353.  463,  636,  778 

Spencer,  17,  176,  305,  307,  347,  363,  857 

Spielmann,  434,  436 

Spiller,  50 

Spindler,  359 

Spitzka,  45,  48,  473,  622 

Stani,  462 

Stanziale,  816,  831 

Stefani,  188,  639 

Stefanowska,  94,  314 

Steiner,  99 

Steinthal,  341 

Stenger,  81 1 

Stenuit,  524 

Stilling,  41 

Stoddart,  825 

Stolper,  876 

Strassmann,  764 

Stratton,  355,  357 

Strieker,  136,  141 

Stromayer,  370 

Strong,  348 

Striimpell,  817,  822 

Sydenham,  22,  358,  751 

Sully,  224,  225,  229,  348 

Swift,  231 


T 

Taalmann,  675 

Taine,  243,  245,  300,  301,  864 
Talamon,  518 
Talbot,  232 
Tambroni,  198,  456 

Tamburini,  99,  100,  loi,  iii,  112,  114, 
216,  221,  266,  439,  459,  506,  520,  524, 
539.  571.  623,  626,  639,  767,  809,  810 
Tanner,  183 
Tanquerel,  782 

Tanzi,  198,  337,  368,  410,  456,  463,  510, 
529,  572,  576,  589,  777 
Tard,  499,  500 
Tarde,  396 
Targowla,  806 


Tarnovski,  497,  667 
Taty,  326 
Taylor,  148 
Teeter,  523 
Tenchini,  63,  526 
Tennent,  302 
Theohari,  51 
Thibault,  279 
Thiebierge,  456 
Thier}^,  201 
Thomas,  52,  70 
Thompson,  80,  251 
Thomson,  410,  483,  520 
Tillmann,  870 
Tirelli,  526,  761 
Tischer,  191 
Tissie,  213 

Titchener,  221,  246,  247 
Todl,  81 
Tomasini,  123 
Tommasoli,  822 

Tonnini,  410,  442,  505,  510,  528,  576,  784 
Tooth,  56 

Toulouse,  213,  214,  247,  248,  531 

Toy,  326 

Tracy,  300 

Traube,  806 

Troisier,  846 

Tschermak,  55 

Tschisch,  231,  517,  522 

Tuczeck,  769,  813,  816 

Tiike,  626,  832 

Turk.  56,  59,  65,  67,  68,  69 

Turner,  55,  147,  695,  807 


U 

Ughetti,  205 
Ugolotti,  63 
Unna,  811 

TJnverricht,  122,  506 
Urbantschitsch,  183 
Urquhart,  818 
Usuelli,  526 
Utroff,  804 


V 

Vailati,  313 
Vallon,  331,  333 
Van  Deventer,  819 
Van  Eden,  626 

Van  Gehuchten,  14,  32,  49,  65,  69,  70, 
86,  88,  90,  91,  94,  121,  463 
Vas,  772 
Vaschide,  312 

Vassale,  468,  524,  762,  807,  81 1 
Vedrani,  728 
Vejas,  69 
Venanzio,  526 
Ventra,  527,  712,  724 
Venturi,  442,  505,  518,  528,  760 
Verga,  Andrea,  208,  628 
Verga,  205,  374,  420,  522,  527 
Vernet,  148 

Vialet,  40,  42,  43,  44,  45,  48,  79,  104,  105, 
248 

Vielle,  505 
Vierordt,  183,  300 
Vignoli,  279 
Villari,  208 


INDEX  OF  AUTHORS 


887 


Virchow,  408,  467 
Vires,  525,  821 

Virgilio,  410,  500,  509,  517,  578 
Virouboff,  499 
Vizioli,  457 

Vogt,  147,  152,  159,  811,  812 
Voisin,  272,  485,  523,  524,  800,  809,  810, 
811,  828,  831 
Volkmann,  183 
Vorster,  806 
Vurpas,  178 


W 

Wadhain,  148 
Wagner,  681,  832 
Waldeyer,  14,  86 
Ward,  346 
Wartmann,  769 
Washburn,  243 

Weber,  183,  192,  193,  523,  653 
Weigert,  34,  65,  66,  71,  75,  77,  95,  96 
Weir,  205 
Weissbach,  10 
Werner,  875 

Wernicke,  40,  42,  76,  77,  576,  586,  619, 
639,  642,  869 

Westphal,  48,  148,  .323,  570,  623,  626, 
644,  769,  814,  820,  823 
Weygand,  678 
Whitehead,  244,  245 
Wiedersheim,  9 
Wieselgren,  499 
Wiglesworth,  804 


Wilbrand,  43,  104,  105,  248 
Wildermuth,  265,  526 
Wide,  623,  634,  642,  71 1,  835 
Willerdich,  683 
Wittich,  192 
Wolfers,  764 
Wolland,  148 
Wolleinberg,  823 
Woodruff,  298 
Wuillamie,  460 
WulfE,  463,  531 

Wundt,  20,  180,  185,  186,  191,  192,  221, 
227,  230,  231,  241,  249,  305,  306,  307, 
346,  347,  348 
Wyllie,  130,  147 


Y 

Yeo,  100,  102 

Z 

Zacher,  69,  791,  81 1,  813,  816 
Zagari,  813 
Zamboni,  244 
Ziegler,  314 

Ziehen,  69,  315,  419,  622,  649,  681,  71 1, 
713.  737.  826 
Zola,  390,  497,  499,  765 
Zollner,  201 

Zuccarelli,  265,  410,  515 
Zuntz,  764 
Zwaardemaker,  183 


INDEX  OF  SUBJECTS 


A 

Accommodation  as  a factor  of  the  sense 
of  space,  187,  188 
in  phrenasthenia,  431 
Acid,  carbamic,  in  the  genesis  of  epi- 
lepsy, 523 

uric,  in  the  genesis  of  epilepsy, 

523 

Acrophobia,  628 
Adaptation,  471 

Adonis  Vernalis,  in  epilepsy,  531 
in  melancholia,  698 
in  alcoholic  insanity,  774 
Age,  evolution  of  attention  according  to, 

233 

frequency  of  illusions  according  to, 
203 

influence  on  delinquency,  499,  500 
on  perceptive  power,  183 
in  relation  to  hysteria,  565 
to  mania,  676 
to  melancholia,  696 
to  memory,  244,  245 
Agitation,  in  acute  delirium,  755,  756 
in  alcoholic  insanity,  766,  767,  771 
in  aphasic  dementia,  865 
in  chorea,  752 
in  cocainic  insanity,  778 
in  mania,  679 
in  melancholia,  691 
in  morphinic  insanity,  776 
in  post-apoplectic  dementia,  851 
in  progressive  paralysis,  801,  807 
in  saturnine  insanity,  781 
in  secondary  dementia,  786 
in  senile  dementia,  841,  844 
in  sensory  insanity,  720 
in  traumatic  dementia,  872 
Agoraphobia,  628 
Agrammatism,  339,  341 
Agraphia,  286 
Akataphasia,  341,  785 
Albinism,  410,  444 
Alcohol  in  the  organic  economy,  764 
Alcoholism.  See  Dipsomania  and  Alco- 
holic insanity 

in  the  genesis  of  hysteria,  565 
in  the  genesis  of  neurasthenia,  657 
in  the  genesis  of  phrenasthenia,  463 
111  relation  to  crime,  476,  477,  488, 
499.  500,  765,  768,  769 


Alcoholism  in  relation  to  epilepsy,  522, 
523,  525,  529,  765,  767,  769 
in  the  aetiology  of  melancholia, 
696 

in  the  aetiology  of  progressive 
paralysis,  817,  818,  819 
in  relation  to  paranoia,  765 
in  relation  to  traumatic  dementia. 
875,  876 
Alexia,  196,  286 
Alogia,  340,  785 
Altruism,  psychology  of,  364 
in  hysteria,  538 
Ambidexterity,  484 

Ambition  in  the  genesis  of  paranoia,  572, 
586 

Amentia.  See  Mental  confusion  and 
Sensory  insanity 
its  place  in  the  classification,  426 
its  relation  with  paranoia,  617 
state  of  consciousness  in,  340 
Amnesia  {see  Memory),  various  forms  of, 
129,  134,  266 
anterograda,  267 

from  lesion  of  the  frontal  lobes. 
283 

111  epilepsy,  517,  519,  520 
progressive,  law  of,  280 
relations  to  aphasia,  288 
retrograda,  267.  873 
verbal,  in  epilepsy,  522 
Amnesic  insanity,  270 
Amnesiphobia,  636 
Amputations,  illusions  after,  204,  205 
Amusia,  286 

Anagnosiasthenia,  652,  654,  655 
Anaesthesia,  in  the  pathogenesis  of 
hysteria,  533  (note) 

Anarchists.  472 

Anger  in  epileptics,  512,  514,  515 
in  delinquents,  485 
psychology  of,  368,  378,  380 
Anguish,  373,  623,  627,  628,  635,  636, 
647,  650,  653,  659,  685,  688,  691,  693, 
771,  780,  841,  850 

Anomalies  of  the  cerebellum,  461,  526 
of  the  cerebrum,  458,  483,  505,  526 
of  the  cranium,  409,  444,  45^,  457. 
466,  483.  505 

of  the  ears,  410,  483 

of  the  eyes,  409,  444,  456,  466,  467. 

505 


888 


INDEX  OF  SUBJECTS 


Anomalies  of  the  face,  409,  455,  456, 
; 457,  466,  467,  483.  505 

of  the  genitals,  410,  438,  444,  456, 
' 457,  661,  663 

of  the  limbs,  410,  456,  457,  467,  483, 

505 

of  the  month,  410 
of  the  nose,  409,  456,  457,  467,  505 
; of  the  sexual  instinct,  660 

of  the  teeth,  410,  456,  467,  483 
of  the  trunk,  410,  456,  457,  467 
Anosmia,  36 

Anthropophagy,  666,  669 
Antipyrine  in  epilepsy,  531 
Antipyrinomania,  631 
Apaty,  doctrine  of,  86,  89,  315 
Apperception,  181,  224 
' Apperceptive  power  in  paranoia,  571, 
574 

i in  progressive  paralysis,  789 

Army,  rarity  of  hysteria  in,  565 
' Arithmomania,  635 
Arsenic  in  epilepsy,  5 3 1 
in  melancholia,  698 
in  mental  confusion,  741 
in  morphinism,  777 

Arthritic  diathesis  as  a cause  of  pro- 
gressive paralysis,  821 
; Asceticism,  382,  565,  600,  608 
Association,  areas  of,  149 
paths  of,  70 
of  ideas  in  infants,  309 
of  ideas,  laws  of,  305,  308,  309 
power  and  form  of,  305 
Associations,  latent,  319 

for  criminal  purposes,  488 
^ influence  of,  on  criminals,  501 

I Asymmetry  in  epilepsy,  505 
1 Asyntactism,  341 
j Astasia-abasia  in  alcoholism,  765 
I Astigmatism  in  epileptics,  505 
; Astraphobia,  629 

Attacks,  apoplectiform  and  epilepti- 
form, in  progressive  paralysis,  796, 
807,  808 

Attention,  definition  of,  169 
j disturbances  of,  in  the  various 

^ mental  affections,  233 

j evolution  of,  according  to  age,  233 

i expectant,  as  a factor  of  illusions, 

I 200,  202,  237 

I examination  of,  in  the  insane,  406 
i influence  of,  on  time  of  reaction,  232 

' the  emotions  upon,  234 

! intensity  of,  as  a factor  of  dimin- 

; ished  or  altered  perception,  194, 

195 

I physiopathology  of,  224 

seat  of,  169,  230 

I in  relation  to  apperception,  181,  224 

to  choice,  388 
to  education,  225,  226 
to  educability  of  phrenasthe- 
niacs,  463 

to  peculiar  motor  phenomena, 
228 

to  rapidity  of  thought,  315 
to  respiration,  circulation,  and 
blood-pressure,  233 
to  sensations  of  pain  or  plea- 
sure, 346 

to  sense  of  time,  185 


Attention  in  relation  to  sentiments,  227 
to  visual  field,  232 
to  will  and  consciousness,  169, 
224 

in  alcoholic  insanity,  770 
in  chorea,  7 5 1 
in  epilepsy,  510 
in  hysteria,  540 
in  mania,  678 
in  neurasthenia,  648,  650 
in  persecutory  paranoia,  586 
in  phrenasthenia,  431,  435 
in  progressive  paralysis,  792 
in  psychopathology  of  obsessions, 
624 

in  sensory  insanity,  721,  722 
in  senile  dementia,  841 
in  traumatic  dementia,  872 
voluntary,  225,  387 

Attitudes  {see  Conduct),  examination  of, 
in  the  insane,  405 
in  delirium  tremens,  771 
in  katatonia,  729 
in  phrenasthenia,  439 
in  sensory  insanity,  722,  723 
passional,  in  hysteria,  557,  566 
sexual,  in  hysteria,  553,  566 

Auditory  centres  and  paths  {see  Hear- 
ing), 45 

Auto-intoxications  in  the  pathogenesis 
of  mental  affections,  670,  672 

Automatism  in  epilepsy,  510 
in  hysteria,  540 
in  neurasthenia,  649 
in  obsessive  impulsions,  635 
in  secondary  dementia,  784 
in  senile  dementia,  843 
in  sensory  insanity,  720,  723,  734 
in  relation  to  attention,  235 
to  memory,  257 
verbal,  342 

Auto-suggestion  as  a source  of  illusions, 
203 


B 

Bacilli  in  chorea,  750 

in  acute  delirium,  755,  757 
Baths  in  mania,  684 

in  melancholia,  698 
in  progressive  paralysis,  831 
in  delirium  tremens,  774 
Basedow’s  disease,  vaso-motor  pheno- 
mena in,  in  relation  to  states  of 
emotion,  354 

Bedsores  in  progressive  paralysis,  805 
Bee,  nervous  system  of,  7 
Behaviour  {see  Attitudes  and  Conduct), 
examination  of,  in  the  insane,  404, 
405 

in  acute  delirium,  756 
paranoia,  743 
in  katatonia,  729 
in  melancholia,  693 
in  phrenasthenia,  439,  440 
in  progressive  paralysis,  790,  792 
in  sensory  insanity,  722,  723 
Belenophobia,  629 
Bladder,  cortical  centres  for,  124 
Blind,  the  phenomenon  of  coloured 
audition  in  the,  205 


890 


INDEX  OF  SUBJECTS 


Blind,  visual  liallucinations  in  the,  215 
Blindness  in  cretins,  467 
in  idiots,  444 

congenital,  compensatory  perceptive 
hyperfunctionality  in  cases  of , 1 9 5 
psychic,  105,  197 

word  {see  Aphasic  dementia),  286,  522 
Blood,  alterations  of,  in  delirium 
tremens,  772 

in  progressive  paralysis,  806 
in  melancholia,  694 
toxicity  of,  in  the  insane,  670,  671 
Blood-letting  in  epilepsy,  531 
in  sensory  insanity,  738 
Blood-pressure  in  relation  to  attention, 
233 

Bradycardia  in  neurasthenia,  653 
Bradylalia,  522,  793 
Brad5rphrasia,  317,  340 
Bromides  in  alcoholic  insanity,  774 
in  epilepsy,  531 
in  mania,  684 
in  melancholia,  698 
in  sensory  insanity,  738 


C 

Canahculi  of  the  nerve-cell,  95 
Canals,  semicircular  and  sense  of  space, 
188 

Capsula  interna,  topographic  distribu- 
tion of  nerve-bundles  in,  66 
Catalepsy  in  senile  dementia,  843 
Catatonia.  See  Katatonia 
Cerebellum  {see  Nerve-cells),  alterations 
of,  in  general  paralysis,  814 
alterations  and  anomalies  of,  in 
epilepsy,  526,  527 

anatomical  relations  of,  with  cere- 
brum in  microcephaly,  461 
in  relation  to  the  psychic  functions, 

174 

Cerebral  convolutions.  See  Cerebrum 
Cerebral  cortex  {see  Nerve-centres  and 
Cerebrum),  alterations  of,  in 
epilepsy,  526,  527 
functional  compensations  in,  120 
minute  anatomy  of,  80 
projection  of  retina  upon,  43,  44 
zones  of  evolution  in,  143,  152,  158, 
288 

Cerebrum  {see  Nerve-cells  and  Cerebral 
cortex),  absolute  and  relative 
weight  of,  in  different  races  and 
different  animals,  10 
alterations  of,  in  acute  deliria,  757 
in  pellagra,  762 

in  progressive  paralysis,  810 
et  seq. 

anatomy  of,  24 

anomalies  of,  in  delinquents,  483 
and  alterations  of,  in  epilepsy, 

505 

in  phrenasthenia,  458 
destructive  foci  of,  as  cause  of 
epilepsy,  505,  525 
histology  of,  80 

relation  between,  and  thought,  4 
{note) 

Character,  change  of,  in  chorea,  750 
in  neurasthenia,  646,  647 


Character,  change  of,  in  progressive 
paralysis,  791 
epileptic,  507 
hysterical,  536 
melancholic,  674 
maniacal,  674 

paranoic,  574,  577,  585,  618 
Chastity,  565 

Chess  players,  memory  in,  245 
Chloralomania  {see  Insanity,  chloralic), 
631 

Chorea.  See  Insanity,  choreic 
Chromatic  sense  {see  Daltonism)  evolu- 
tion of,  181,  303 
in  phrenasthenia,  431 
in  progressive  paralysis,  804 
Chromatolysis,  94,  418,  527,  683,  735, 
750,  757 

Chronoscope,  191,  406 
Circulation,  cortical  centres  of,  122 
influence  of  pain  upon,  358,  359 
relations  between  attention  and,  233 
states  of  pleasure  or  pain 
and,  350 

Civilization,  conception  of,  i 
gradations  of,  2 

in  the  aetiology  of  delinquency,  497 
of  progressive  paralysis,  825 
Classification  of  the  mental  affections,  416 
Claustrophobia,  628 
Cocainomania,  631,  633 
Collapse  in  acute  delirium,  755,  756,  759 
in  alcoholic  insanity,  766,  770 
in  chorea,  752 
in  cocainic  insanity,  779 
in  progressive  paralysis,  808 
in  saturnine  insanity,  781 
in  sensory  insanity,  739 
Collectionism  in  the  insane,  405,  439, 
472,  724,  786 
Coloured  audition,  205 
Conceptualism  in  relation  to  the  epoch 
and  civihzation,  279 
its  relations  with  nominalism,  294, 

864 

with  sensorialism,  296,  297 
Conduct  {see  Behaviour),  examination 
of,  in  the  insane,  405 
in  delinquency,  478 
in  eccentricity,  472 
in  epilepsy,  507 
in  hemiplegia,  850 
in  hysteria,  537,  538,  556,  558,  559 
in  mania,  677,  683 
in  melancholia,  693,  694 
in  neurasthenia,  647 
in  obsessions,  626,  627 
in  paranoiacs,  585,  586,  600,  607, 
608,  614 

in  phrenastheniacs,  433,  436,  440, 
441 

in  progressive  paralysis,  788,  789, 
792 

in  senile  dementia,  844 
in  sensory  insanity,  722,  723 
Confusion,  mental,  339,  648,  740,  752, 
857,  865 

Consciousness.  See  Unconsciousness 
anatomical  seat  of,  167,  398 
altered  power  of  elimination  of  the, 

318 

behaviour  of,  in  hallucinations,  222 


1 


i 

I 

i 

i 


\ 

'< 


INDEX  OF  SUBJECTS 


891 


Consciousness,  evolution  of,  167,  398 
examination  of,  in  the  insane,  402 
in  acute  delirium,  755 
in  amentia,  340,  865,  866 
in  aphasic  dementia,  872 
in  apoplexy,  848 
in  epilepsy,  520 
in  katatonia,  722 
in  obsessions,  623 
in  paranoia,  570 

in  progressive  parah^sis,  807,  808 
in  sensory  insanity,  720,  721,  722 
in  traumatic  dementia,  872 
. in  relation  to  attention,  224,  225 
to  kinaesthesis,  344 
to  memory,  257,  269 
to  sense  of  time,  186 
to  the  emotions,  353 
of  matter,  292 
origin  of,  177 
psychology  of,  393 
duplication  of,  in  epilepsy,  519 
in  hysteria,  535 
social,  396 

Contractures  in  progressive  paralysis, 
803 

Contrast  in  fear,  368 

in  genesis  of  deliria  in  general,  322, 

335 

in  hysteria,  537,  560,  565 
in  melancholic  deliria,  689 
in  obsessions,  628,  629,  633 
psychic  importance  of,  in  psy- 
chology, 308 
3oprophobia,  636 
3oprophrasia,  342 
Coprolalia,  342,  635 

Corpus  striatum,  alterations  of,  in 
epilepsy,  527 
Corti,  organ  of,  45,  215 
Iranium,  alterations  of,  in  progressive 
paralysis,  810 

anomalies  of,  409,  444,  456,  457, 
466,  483,  505 

measurement  of,  in  the  insane, 
409 

trephining  of,  in  progressive  para- 
lysis, 832 

sedulity  in  hysterical  subjects,  540 
in  paralytics,  797 
in  phrenastheniacs,  436,  442 
retinism,  429,  430,  466 
riminality.  See  Delinquency 
Iruelty  in  delinquents,  484,  485,  487, 

I _ 489 

in  epileptics,  5 1 1 
; in  paranoiacs,  588 
fulture  and  deliria,  and  relation  be- 
f tween,  325 

I yclostomata,  nervous  system  of,  8 
^oklasis,  95 
Ttolysis,  95,  418,  423 
7tothesis,  95 


D 

altonism,  194,  484 

eaf-mutism,  congenital,  compensatory 
' perceptive  hyperfunctionality  in 

: cases  of,  195 

in  idiots, 


Deafness  in  cretins,  467 

word-.  See  Word-deafness  and  De- 
mentia, aphasic 

Deffecation,  cortical  centres  of,  123 
Degenerative  stigmata.  See  Stigmata 
of  degeneration 

Deglutition,  cortical  centres  of,  123 
Delinquency,  aetiology  of,  497 

and  alcoholism,  476,  477,  488,  499, 
500,  765,  768,  769 
and  epilepsy,  476,  500,  511,  521 
and  phrenasthenia,  475,  477 
attention  in,  237 

classification  and  symptomatology 
of,  483 

conception  of,  475 
hysterical,  540 
in  woman,  496 

in  relation  to  hysteria,  497,  540 
to  neurasthenia,  648 
prognosis  and  therapy  of,  502 
vanity  in,  381 
Delinquents,  political,  473 
Deliria,  different  forms  of,  in  the  various 
mental  affections,  324 
examination  of,  in  the  insane,  404 
in  acute  delirium,  756 
paranoia,  742,  743 
in  alcoholic  insanity,  766,  771 
in  cocainic  insanity,  778 
in  dementia  aphasic,  865 
luetic,  834 
post-apoplectic,  851 
secondary,  783,  784 
senile,  844 
traumatic,  872 
in  epilepsy,  513,  514,  521 
in  hysteria,  557,  560 
in  late  paranoia,  745 
in  mania,  678,  680,  681 
in  melancholia,  694,  696 
in  obsessions,  641,  642 
in  paranoia,  570,  571 
in  progressive  paralysis,  791,  792, 
797’  799’  807,  809,  826,  827 
Deliria  in  saturnine  insanity,  782 

in  sensory  insanity,  711,  713,  721, 

. 722,  723,  725.  729.  730,  733 
in  syphilitic  insanity,  754 
relation  between  culture  and,  325 
Delirium,  acute,  755 

acute  sensory.  See  Insanity,  sen- 
sory 

of  recognition,  278,  280,  338 
tremens,  770 

Dementia,  acute.  See  Insanity,  sen- 
sory, and  Mental  confusion 
its  place  in  the  classification, 
426 

memory  in,  276 
aphasic,  855 
attention  in,  236 
ideation  in,  320 
in  paranoia,  589 

in  progressive  paralysis,  797,  826 
luetic  {see  Insanity,  luetic),  833 
memory  in,  277,  278,  280,  282 
{note) 

paralytic.  See  Progressive  para- 
lysis 

post-apoplectic,  848 
praecox,  conception  of,  723 


892  INDEX  OF  SUBJECTS 


Dementia  praecox,  its  place  in  the  classi- 
fication, 426 

its  relations  with  hysteria,  725 
with  sensory  insanity,  704, 
705,  711,  712,  719,  723 
secondary,  428,  783 
senile,  838 
traumatic,  870 

Desire  in  the  genesis  of  pleasure  and 
pain,  346,-  347 

what  it  consists  in,  363,  388 
Desires,  obsessive,  626,  631 
Despair,  in  melancholia,  687 
Determination  of  actions,  388 
Diastem.  See  Teeth 
Dipsomania,  631,  632 
Discrimination,  197 
Distraction,  232 

in  neurasthenia,  648 
Doubt,  insanity  of,  376,  626,  649 
Dreams,  deliria  arising  from,  336,  337 
in  acute  paranoia,  742 
in  alcoholic  insanity,  767 
in  dementia,  luetic,  834 
praecox,  725 
senile,  841 
in  epilepsy,  513 
in  hemiplegia,  851 
in  hysteria,  540,  560 
in  mania,  prodromal  period,  677 
in  neurasthenia,  650 
in  paranoia,  586,  600,  609 
in  saturnine  insanity,  781 
influence  of,  in  paramnesias,  280 
in  hallucinations,  213,  214 
mechanism  of,  213,  214 
Dwarfism,  409,  457 
Dysgrammatism,  341 
Dyskinesis,  professional,  652 
Dyslogia,  340 
Dysmnesia,  278,  280 
Dysmorphophobia,  375 
Dysphrasia,  imitative,  342 


E 

Ears,  anomalies  of,  410 
Eccentricity,  470,  471 
Echinoderms,  nervous  system  of,  7 
Echolalia,  196,  342,  522,  729 
Echophrasia,  342 
Echopraxia,  729 

Eclampsia,  424,  455,  468,  521,  525 
Ecstasy,  213,  238,  364,  382,  557,  559 
Ectoderm,  sensitive,  in  the  medusae,  7 
Educability  of  delinquents,  479,  480,  500, 
501 

of  phrenastheniacs,  435,  463,  465 
Education  in  relation  to  attention,  226 
in  pathogenesis  and  treatment  of 
hysteria,  565,  568 
Egoism,  psychology  of,  364,  365 
in  hemiplegia,  850 
in  hysteria,  538,  560 
in  senility,  840,  841 
Electricity  in  hysteria,  569 
in  melancholia,  698 
in  mental  confusion,  741 
in  morphinism,  777 
in  progressive  paralysis,  832 
in  sensory  insanity,  738 


Embolophrasia,  342 
Emotions.  See  Sentiments 

anatomical  seat  of,  350,  352  {note) 
and  ideas  in  mechanism  of  choice 
388 

description  of  the  principal,  365 
essence  and  nature  of,  352,  365 
evolution  of,  355,  361,  364  1 

examination  of,  in  the  insane,  404, 
406  I 

fundamental  forms  of,  352  | 

importance  of,  in  mental  pathologv,  I 
.372  I 

influence  of,  upon  attention,  234  i 
in  phrenastheniacs,  437  | 

in  psychopathology  of  the  obses-  ' 
sions,  622  ; 

memory  of,  246  i 

obsessive,  626 

and  deliria,  relations  between,  337 
and  kinsesthesis,  relations  between, 

345.  350 

and  will,  relations  between,  386 
and  thought,  relations  between,  418, 

570 

physio-pathology  of,  343 
somatic  concomitants  of,  352,  369 
Emotive  states  as  factors  of  illusions, 
199,  204 

in  process  of  revivification,  256, 
257 

Emotivity  in  aphasic  subjects,  857 
in  delinquents,  489 
in  neurasthenia,  646,  647 
in  obsessions,  622 
in  paraphrenia,  472 
in  post-apoplectic  dementia,  853 
in  progressive  paralysis,  795 
in  secondary  dementia,  783 
in  senility,  840,  841  ' 

in  traumatic  dementia,  875 
Encephalon,  relative  weight  of  different 
parts  of  the,  1 1 f 

Environment  of  the  insane,  inquiry  into,  ■ 
411,  414,  415 

influence  of,  on  delinquency,  479, 

501 

in  the  pathogenesis  and  treatment 
of  hysteria,  565,  569 

Epilepsie  larvee  (masked  epilepsy),  512,  • 
516,  528  ' 

Epilepsy,  aetiology  of,  522 

anger  in,  378"  -p 

attention  in,  237  | 

conception  of,  503 
diagnosis,  528 

in  relation  to  alcoholism,  522,  523, 
525,  529,  765,  767,  769 
to  delinquency,  476,  500,  503, 
511,  520,  521 
to  genius,  510 
to  hemiplegia,  532,  852 
to  hysteria,  565 
to  mania,  674 
to  myoclonus,  522 
to  other  psychoses,  511,515.5^^ 
to  paranoia,  503,  509,  510.  514 
to  phrenasthenia,  455,  458,  4^4 
to  progressive  paralysis,  529 
to  sensory  insanity,  737 
to  syphilis,  754,  836,  837 
to  traumatic  dementia,  874 


INDEX  OF 


Epilepsy,  its  place  in  the  classification, 

423.  424 

memory  in,  266,  269,  270,  275 
morbid  gaiety  in,  380 
pathological  anatomy  of,  526 
prognosis,  530 
secondary  dementia  in,  784 
symptomatology  of,  512 
treatment,  530 

Epileptic  character,  507,  512,  521 
equivalents,  512,  516,  528 
Equilibrium  in  the  sense  of  space, 
organs  of,  188 
Eremnophobia,  629 
Ereutophobia,  357,  373,  375,  635 
Ergographic  researches  in  melancholia, 

695 

Ergography,  407 

Ergot  of  rye  in  progressive  paralysis, 
831 

Eroticism  from  psychic  contrast,  310, 
323 

in  delirium  tremens,  771 
in  hysteria,  556,  557,  559,  560,  561, 
565,  566 

in  mania,  680 
in  paranoia,  607,  662 
in  phrenasthenia,  438 
in  progressive  paralysis,  790,  795, 
809 

in  senile  dementia,  846 
Ethics.  Sec  Sentiment,  moral 
Evocation  of  the  impressions,  252, 

255 

Evolution,  cortical  zones  of,  143,  155, 
158,  288 

Exaggeration,  delirium  of,  800 
Excesses,  sexual  {see  Onanism),  in  hy- 
steria, 662 

in  neurasthenia,  650,  651,  652, 
656,  658,  662 

paralytic  dementia,  662,  791, 
818 

senile  dementia,  662 
Exhibitionism,  497,  513,  518,  680 
Eyes,  anomalies  of  the,  409,  410,  444, 
456,  467,  505 


F 

Face,  anomalies  of  the,  409,  455,  456, 
457.  466,  483,  505 

Family  of  the  insane,  inquiry  into, 
411' 

Family,  the  sentiment  of,  166,  382 
Fear.  See  Phobias 

and  anguish,  373,  375 
genesis  of,  356 

in  alcoholic  insanity,  766,  771 
in  chorea,  751 
in  genesis  of  paranoia,  571 
in  melancholia,  688,  690,  694,  696 
obsessions  of,  374 
psychology  of,  367 
relations  to  suspicion,  377 
Feet,  anomalies  of  the,  410,  456,  483 
Fetishism,  667 

Fibre,  muscular,  first  appearance  in 
ph}dogenesis,  6 

nervous,  alterations  of,  in  pro- 
gressive paralysis,  812 


SUBJECTS  893 

Fibres,  nervous,  associative,  bundles  of, 

71 

first  appearance  in  phylo- 
genesis, 6 

tangential,  of  cerebral  cortex,  8 1 
Field  of  vision  in  anger,  369 
in  delinquents,  484 
in  progressive  paralysis,  804 
and  attention,  232 
Fish,  nervous  system  of,  8 
Flechsig,  doctrine  of,  149 
Force,  muscular,  in  delinquents,  484 
in  progressive  paralysis,  802 
Free  will,  389 
Frigidity,  sexual,  661,  669 
Frontal  lobes,  amnesia  resulting  from 
lesion  of,  283 

function  of,  162,  230,  249,  253, 
254,  351  {note),  398 
traumatic  dementia  from  lesion 
of,  871,  872 
Furor,  369,  682,  766 
Furunculosis  in  paralytics,  806 


G 

Gaiety,  morbid,  378 
Gait  in  idiots,  439 

in  paralytics,  803 
Gemmules,  176 

Genitals,  anomalies  of,  410,  438,  444, 
456,  457,  661 
Genius  and  epilepsy,  510 

in  paraphrenia,  470,  472 
Giantism,  409,  457,  467 
Glomerules,  olfactory,  32 
Goitre  {see  Thyroid)  in  cretinism,  466, 
467,  46S 

Golgi,  doctrine  of,  86,  90 


H 

Habit  and  adaptation,  471 
law  of,  2,  226,  31 1 

Habitations,  influence  of,  on  cretinism, 
469 

on  criminality,  499 

Hallucinations,  definition  of,  206 
degree  and  content  of,  209 
determining  mental  confusion,  340 
different  kinds  of,  209 
differentiated  from  illusions,  206 
effect  of,  on  conduct,  210 
examination  of,  in  the  insane,  403 
hypnogogic,  207,  214 
influence  of,  on  the  conduct,  210 
on  the  consciousness,  222 
on  the  emotive  states,  21 1 
on  the  rapidity  of  thought,  315 
in  acute  delirium,  755,  756 
in  paranoia,  742 
in  alcoholic  insanity,  767,  771 
in  chloralic  insanity,  780 
in  choreic  insanity,  752 
in  cocainic  insanity,  778 
in  ecstasy,  382 
in  epilepsy,  506,  513,  521 
in  fixed  ideas,  639 
in  hysteria,  557,  560 
in  late  paranoia,  745 


I 

894  INDEX  OF  SUBJECTS 


Hallucinations  in  luetic  dementia,  834 
in  mania,  680 

in  melancholia,  686,  691,  693 
in  mental  confusion,  740,  741 
in  morphinic  insanity,  776 
in  paranoia,  570,  576,  578,  586,  600, 
610,  616 

in  polyneuritic  psychosis,  741,  826, 
827 

in  post-apoplectic  dementia,  851,852 
in  progressive  paralysis,  801 
in  religious  delirium,  334 
in  sane  and  insane  persons,  207 
in  saturnine  insanity,  781,  782 
in  secondary  dementia,  784 
in  senile  dementia,  841,  844 
in  sensory  insanity,  704  et  seq. 
in  systematized  delirium  of  perse- 
cution, 333,  335 

in  traumatic  dementia,  872,  873 
mode  of  origin  of,  214 
pseudo-hallucinations,  209 
statistical  data  of,  207 
symptomatic  value  of  the  various, 
223 

Hands,  anomalies  of,  410,  444,  456,  483, 

505 

Hatred  in  the  epileptic  character,  509 
Hearing,  centre  and  paths  of  the  sense  of, 

45 

function  of,  in  the  sense  of  space,  188 

in  cretins,  467 

in  idiots,  431 

organ  of,  in  cetaceans,  48 

its  importance  and  function, 
in  language,  126 

Heart,  influence  of  pain  upon,  358,  359 
Hebephrenia.  See  Dementia  prsecox, 
470,  725,  726,  728,  735 
Heliotropic  phenomena,  5,  177 
Hemianosmia,  36 

Hemiplegia.  See  Dementia,  post-apo- 
plectic 

emotivity  in,  357,  358 
relations  with  epilepsy,  532,  852 
Heredity  examination  of,  in  the  insane, 
412 

factors  of,  in  genesis  of  phrenas- 
thenia,  462,  464 
in  epilepsy,  522,  525 
in  delinquency,  477,  497 
in  different  forms  of  memory,  261 
in  hysteria,  565 
in  melancholia,  696,  697 
in  obsessions,  642 
in  paraphrenia,  473 
in  progressive  paralysis,  817,  818, 
819,  820 

in  sexual  perversions,  664,  666,  668, 
669 

Homosexuality,  663 
Hydrocephaly,  444,  459,  463,  464,  521 
Hydrophobia,  629 
Hydrotherapy/  in  alcoholism,  774 
in  melancholia,  698 
in  mental  confusion,  741 
in  progressive  paralysis,  831 
in  sensory  insanity,  738 
Hypermnesia,  262 
Hyperprosessis,  235,  237 
Hypnotics  in  mania,  684 

in  sensory  insanity,  738 


Hypnotism,  attention  in,  237 
consciousness  in,  213 
in  genesis  of  hysteria,  566 
memory  in,  258,  262,  275,  290 
in  treatment  of  hysteria,  569 
of  morphinomania,  777 
of  obsessions,  644,  645 
Hypoalgesia  in  delinquency,  484 
Hypochondriacal  delirium,  328,  330, 

690,  733>  745.  748,  800 
Hypochondriasis,  attention  in,  237 
in  neurasthenia,  647,  651 
in  progressive  paralysis,  793,  800 
in  senility,  840 

Hypodermic  transfusion  in  acute  de- 
lirium, 759 

in  choreic  insanity,  752 
in  delirium  tremens,  774 
in  epilepsy,  531 
in  mania,  684 
in  melancholia,  698 
in  sensory  insanity,  738 
Hypoprosessis,  234,  237 
Hysteria,  aetiology  of,  565 
anger  in,  378 
anguish  in,  374 
conception  of,  533 
diagnosis  of,  567 
different  clinical  forms  of,  558 
memory  in,  258,  263,  269,  272,  275, 
290 

morbid  joy  in,  380 
pathological  anatomy  and  physio- 
pathology  of,  563 
place  in  classification,  423,  424 
prognosis  and  treatment  of,  568 
relations  to  dementia  praecox,  725  . 

to  dementia,  traumatic,  873 
to  epilepsy,  565  ^ 

to  katatonia,  729  I 

to  morphinomania,  775 
in  neurasthenia,  659  ? 

to  obsessions,  638  i 

to  sensory  insanity,  737  : 

to  syphilis,  837 

sentiment  of  love  in,  384  ; 

symptomatology  of,  536 
termination,  563 

vanity  in,  380  I 

vaso-motor  phenomena  in,  in  rela-  1 
tion  to  states  of  emotion,  354  | 

Hysterical  character,  536  { 

delinquency,  540  ) 

4 

I .! 

Ideas  and  emotions  in  mechanism  of  . 
choice,  388 
association  of,  305 
emotions  and  will,  relations  between, 
386 

fixed.  See  Phobias  and  obsessions 
aetiology  of,  642 
attention  in,  235 
classification  and  forms  of,  625 
conception  of,  620 
difference  between  paranoia 
and,  622 

in  the  genesis  of  hysteria,  533 
{note) 

psychopathology  of,  622 


INDEX  OF  SUBJECTS  895 


Ideas,  fixed,  prognosis  of,  642 

relations  with  hysteria,  638 
with  melancholia  agitans, 
642 

treatment,  643 

Ideation.  See  Ideas  and  Thought 

anomalies  of,  in  the  various  mental 
affections,  315 

examination  of,  in  the  insane,  403, 
407 

in  acute  delirium,  756 
in  alcoholic  insanity,  767,  770 
in  aphasia,  857,  858 
in  chorea,  751 
in  delinquents,  492 
in  dementia,  post-apoplectic,  850 
secondary,  783 
traumatic,  872 
in  epilepsy,  510,  521 
in  mania,  677,  679 
in  neurasthenia,  648 
in  phrenasthenia,  433 
in  progressive  paralysis,  791,  792, 
801 

in  sensory  insanity,  72 1 
physio-pathology  of,  291 
Idiocy.  See  Phrenasthenia 
Illiterate,  mechanism  of  language  in  the, 

139 

Illusions  and  errors,  difference  between, 
199 

and  hallucinations,  difference  be- 
tween, 206 
and  suggestion,  203 
definition  of,  199 
different  kinds  of,  200 
frequency  and  intensity  of,  accord- 
ing to  age,  203 
in  acute  paranoia,  743 
in  mania,  680 
in  melancholia,  686 
in  paranoia,  586,  600,  608,  610 
in  progressive  paralysis,  801 
in  sensory  insanity,  704 
of  memory,  282 
Imagination,  206 
Imbecility.  See  Phrenasthenia 
Imitation  in  hysteria,  540,  566 
Immorality.  See  Moral  sentiment 
Impotence,  sexual,  in  alcoholists,  767, 
770 

in  morphinic  insanity,  776 
in  neurasthenia,  652,  654,  655 
in  progressive  paralysis,  793, 
795,  829 

in  sexual  perversions,  669 
Impulses  {see  Impulsiveness)  in  acute 
paranoia,  743 

. in  sensory  insanity,  733,  734 
obsessive,  633 

Impulsiveness  in  alcoholic  insanity,  766 
in  aphasic  dementia,  865 
in  delinquency,  489 
in  epilepsy,  504,  507,  508 
in  paranoia,  588 
in  progressive  paralysis,  801 
Infantilism  {see  Myxoedema),  661 
Infants,  association  of  ideas  in,  309 
language  in,  298,  300,  301 
sense  of  space  in,  187 
Infections  in  the  aetiology  of  mental 
affections,  670 


Influenza  in  aetiology  of  sensory  in- 
sanity, 735 

Inhibition,  conception  of,  170 
in  epilepsy,  508 
in  hysteria,  537 
in  mania,  678,  679 
in  mechanism  of  choice,  388 
in  morbid  gaiety,  379 
in  process  of  attention,  230 
in ’progressive  paralysis,  792 

Insane,  interrogatory  examination  of  the, 
401 

Insanity,  alcoholic.  See  Alcoholism  and 
Dipsomania 

pathological  anatomy  of,  772 
relations  to  sensory  insanity, 
737 

symptomatology  and  clinical 
forms  of,  765 
treatment  of,  773 
amnesic,  270 

chloralic  {see  Chloralomania),  780 
choreic,  750 
circular,  380,  701 
cocainic  {see  Cocainomania),  778 
hypochondriacal.  See  Hypochon- 
driasis, and  Insanity,  neurasthenic 
luetic  {see  Dementia,  luetic),  753 
maniacal-depressive,  701,  754 
moral.  See  Delinquency 
morphinic  {see  Morphinomania),  775 
neurasthenic.  See  Neurasthenia 
pellagrous,  setiology  of,  761 

definition  and  symptomatology, 
760 

pathological  anatomy  of,  762 
relations  to  progressive  para- 
lysis and  tabes,  762 
treatment  of,  762 
periodical,  700 

polyneuritic,  memory  in,  275,  741 
puerperal,  427 
saturnine,  781 
sensory,  aetiology  of,  734 
attention  in,  236 
clinical  forms  of,  705 
conception  of,  704 
diagnosis  of,  735 
memory  in,  275 
morbid  joy  in,  380 
pathological  anatomy  of,  735 
place  in  classification,  426 
prognosis,  737 

relations  to  acute  delirium,  737, 
755 

to  dementia,  to  amentia, 
to  dementia  praecox,  to 
katatonia,  to  stupor,  and 
to  mental  confusion,  704, 
705,  711,  712,  713,  720, 
7^3 

to  acute  paranoia,  713, 
736 

to  epilepsy,  alcoholic  in- 
sanity and  hysteria,  737 
to  mania,  674,  680,  681, 
735 

to  melancholia,  736 
to  progressive  paralysis, 
735 

symptomatology  of,  705 
treatment  of,  738 


896 


INDEX  OF  SUBJECTS 


I 


Insects,  nervous  system  of,  7 
Instinct,  sexual.  See  Eroticism  and 
Perversions 

in  genesis  of  hysteria,  566 
in  mania,  677 
in  melancholia,  695 
in  paranoia,  607,'  608 
in  phrenasthenia,  438 
impulsiveness  of,  in  hysteria, 
556,  557.  559.  561.  565 
pathology  of,  660 
precocity  of,  in  delinquency, 
486,  663 

in  epilepsy,  507,  508,  663 
repression  of,  in  hysterical 
natures,  565 

Intellect.  See  Ideation  and  Thought 
anatomical  seat  of,  313 
and  language,  relations  between, 
863 

and  notion  of  time,  relation  between, 
185,  186 

cortical  centre  of,  129,  163 
definition  of,  4 

first  manifestations  of,  4 {note),  176 

in  alcoholic  insanity,  770 

in  delinquency,  491 

in  epilepsy,  509,  510 

in  hysteria,  539 

in  plastiduli  and  protozoans,  4 

limits  of,  4 

of  idiots  compared  with  that  of 
monkeys  and  dogs,  433 
of  matter,  universal,  4 
perception  as  the  foundation  of,  197 
Interference,  phenomena  of,  in  associa- 
tion, 31 1 

in  perception,  182 
Interrogation  of  the  insane,  401 
Intestine,  cortical  centres  for  move- 
ments of,  123 

Intoxications  in  aetiology  of  mental 
affections,  670 

Iodides  in  alcoholic  insanity,  774 
in  progressive  paralysis,  831 


J 

Jealousy,  delirium  of,  589 
in  hysteria,  560 
in  neurasthenia,  647 
in  phrenasthenia,  438 
Joy,  366 

morbid,  378,  380,  676 
Judgment,  defect  of,  in  delirium  of  pro- 
gressive paralysis,  798 
in  paranoia,  570,  589,  615 
in  senile  dementia,  841,  846 
power  of,  in  eccentric  individuals, 
470 

Judgments  and  propositions,  313 


K 

Katatonia,  693,  697,  728,  729,  875 
Kinaesthesis,  anatomical  basis  of,  350 
and  consciousness,  relations  be- 
tween, 344 

and  emotions,  relations  between, 

352 


Kinaesthesis,  definition  of,  343 

examination  of,  in  the  insane,  410 
in  dementia  praecox,  725 
in  hysteria,  533,  558 
in  insanity  of  doubt,  376 
in  mania,  676 
in  melancholia,  692,  695 
in  morbid  gaiety,  379 
in  neurasthenia,  646,  654 
in  obsessions,  627,  632 
in  progressive  paralysis,  789,  971, 
799,  800 

Kleptomania,  634 


L 


I.actation  as  a cause  of  neurasthenia,  657 
Language.  See  Aphasia  and  Speech 
analysis  of  factors  of,  126 
and  thought,  relations  between,  303, 
863 

disturbances  of,  285 
emotional,  127,  148 
evolution  of,  297 
in  alcoholists,  766,  770 
in  cretins,  468 
in  illiterate  persons,  139 
in  infants,  298,  300 
in  maniacs,  677,  680 
in  men  who  read  and  write,  140 
in  paranoiacs,  589 
in  phrenastheniacs,  430,  443 
in  progressive  paralytics,  790,  791 
law  of  articulation  of  sounds  in 
infants,  301  {note) 
re-education  in,  865 

Laughter,  370,  371,  852,  853  ; 

Leeching  in  acute  delirium,  759 

in  epilepsy,  530  ' 

in  mania,  684  ! 

in  sensory  insanity,  738 
Left-handedness,  484,  505  : 

Legislation  in  relation  to  delinquency,  i 
502  > 

Life,  conception  of,  4 

evolution  of,  in  relation  to  evolu-  ; 

tion  of  nervous  system,  6,  7 
psychic,  3,  4 

universal  laws  of,  4 ! 

Limbs,  anomalies  of,  410,  456,  457,  467.  | 

483.  505  , 

Lisping,  794  I 

Litigiousness,  614  ; 

Little’s  disease,  70,  454,  461,  463  . 4 

Liver.  See  Secretions 
Localizations,  doctrine  of  the  cerebral,  I 
99  et  seq. 

Look,  metallic,  in  epilepsy,  522 
Love,  psychopathology  of  sentiment  of. 


383 

sentiment  of,  in  paranoia,  572,  589, 
596,  607,  608 

Lycanthropy,  328,  600,  689 
Lying  in  delinquents,  488,  491 

in  hysterical  subjects,  537,  538,  540 


M 

Malaria  in  aetiology  of  neurasthenia,  657 
of  phrenasthenia,  464 
Mammae.  See  Secretions 


INDE^  OF  SUBJECTS 


897 


Mania,  aetiology  of,  675 
attention  in,  236 
clinical  forms  of,  677,  699 
diagnosis  of,  682 
duration  of,  682 
hysterical,  558 
in  traumatic  dementia,  874 
memory  in,  258,  263,  275 
morbid  joy  in,  380 
nature  of,  676 

pathological  anatomy  of,  682 
prognosis  of,  683 
rarity  of,  674 

relations  to  acute  delirium,  681 
to  epilepsy  and  hysteria,  674 
to  melancholia,  673 
to  progressive  paralysis,  674, 
681 

to  sensory  insanity,  674,  680 
681 

symptomatology  of,  676,  677,  699 
termination  of,  682,  683 
treatment  of,  683 
vanity  in,  381 
Maniacal  character,  674 
Mantle,  cerebral.  See-  Cerebral  cortex 
anatomical  sketch  of,  24 
phylogenetic  development  of,  8 
physiology  of,  98 
synthesis  of  function  of,  172 
Masochism.  385,  667,  668 
Massage  in  alcoholic  insanity,  773 
in  melancholia,  698 
in  morphinism,  777 
Matter,  consciousness  of,  292 
Medulla  oblongata,  alterations  of,  in 
epilepsy,  527 
spinal.  See  Nerve-cells 

alterations  of,  in  pellagra,  762 
in  phrenasthenia,  462 
in  progressive  paralysis,  8 1 4 
motor  paths  in,  59 
paths  for  painful  sensibility 
349.  350 

sensory  paths  in,  48 
Medusae,  nervous  tissue  of,  7 
organ  of  vision  of,  1 2 
Melancholia,  aetiology  of,  696 
attention  in,  237 

clinical  forms  and  symptomatology 
of,  686,  699 
definition  of,  685 

difference  from  neurasthenia,  648, 
696,  747 
hysterical,  559 
memory  in,  275,  276 
pathological  anatomy  of,  6915 
relations  to  dementia  praecox  and 
circular  insanity,  685 
to  katatonia  and  mental  con- 
fusion, 693 
to  mania,  673 

to  progressive  paralysis,  696 
to  sensory  insanity, '736 

to  stupor,  693,  697 
sentiment  of  family  in,  382,  383 
of  love  in.  383,  384 
treatment  of,  698 

Memory,  anatomical  seat  of,  248,  253, 
290 

and  consciousness,  relation  between, 
257 


j Memor}^  and  heredity,  261 

and  perception,  relation  between, 
243 

definition,  240 

different  kinds  of,  244,  259,  263, 
296 

disturbances  of,  in  the  different 
mental  affections,  262 
I examination  of,  in  the  insane,  403, 

‘ . 406 

in  alcoholic  insanity,  770 
in  chloralic  insanity,  780 
in  delinquency,  491 

j in  epilepsy,  510,  514,  517,  519,  520, 

i . 521,  522 

in  hysteria,  540 
in  mania,  677 
in  neurasthenia,  648 
in  phrenasthenia,  435 
in  post-apoplectic  dementia,  849, 
850,  851 

in  progressive  paralysis,  791,  792, 
805 

in  relation  to  the  inidividual,  age, 
sex,  and  race,  260  {note) 
in  sensory  insanity,  722 
in  senility,  839,  841 
in  the  mechanism  of  choice,  388 
in  the  state  of  gaiety,  379 
in  traumatic  dementia,  872,  873, 
874 

influence  of  stimulants  upon,  263 
importance  of,  239 
laws  of,  241,  258 
of  emotional  states,  246 
Meninges,  alterations  of,  in  acute  de- 
lirium, 757 
in  epilepsy,  526 
in  pellagra,  762 
in  progressive  paralysis,  808, 
810 

Mental  affections,  classification  of,  416 
intoxications  and  infections  in 
the  aetiology  of,  670 

Mercury  in  treatment  of  progressive 
paralysis,  830 
Mericism,  439 
Mesolithic  period,  298 
Metabolic  delirium,  338,  691 
Metallophobia,  629 
Metamorphosis,  delirium  of,  328,  689 
^ Metaphysics  and  positivism,  4 
Methods  of  clinical  inquiry,  401 
1 Microcephaly.  See  Cranium,  anomalies 

I 

I Micromaniacal  delirium,  800 
! Microphthalmia,  410,  444 
I Microprosopia.  See  Face 
j Micro-organisms  {see  Bacilli)  in  the 
I pathogenesis  of  mental  affections,  670, 
i 671 

I Micturition,  cortical  centres  for,  124 
! Migratory  paranoiacs,  588 
J Milk.  See  Secretions 
Mimicry,  371,  853 

I Mind  and  nervous  system,  relations  be- 
j tween,  9 

and  somatic  state,  relations  be- 
j tween,  20 

I conception  of  the  evolution  of,  i 

I of  the  stratifications,  grafts, 

1 and  heredity,  2 

57 


898  INDEX  OF  SUBJECTS 


Mind,  first  manilestations  and  evolution 
of,  176 

fundamental  factors  of,  177 
laws  of,  8 

])arallel  between  mental  life  and 
somatic  life,  176 
what  it  is,  i /(■> 

Misanthropes,  472 

Misery  in  adiology  of  delinquency  and 
prostitution,  497,  409 
of  neurasthenia,  657 
Mogigraphia,  652,  654,  655 
Molecules,  physiological,  176 
Monads,  manifestations  of  mental  life 
in,  176 

Monoplegia,  61,  119 
Morality.  See  Sentiment,  moral 
Morphinomania.  See  Insanity,  mor- 
phinic,  631,  632,  640 
Motor  centres  and  paths,  59,  108 

importance  and  function 
of,  in  language,  126  et  sec/. 
Movements,  importance  of,  in  memory. 
242 

in  notion  of  time,  185 
involnntary,  in  emotions,  370 
voluntary,  factors  of,  113 
Music,  in  attention,  232 
Mvelopexia,  240 

Myoclonus,  relations  to  epilepsy,  522 
Mysophobia,  628 
Mysticism,  368.  381,  560,  565 
Myxine,  nervous  system  in  the,  8 
Myx oedema,  429,  455,  466 


N 

Nausea  in  neurasthenia,  650 
Necrophily,  666,  669 
Negation,  delirium  of,  328,  690,  691,  800, 
840 

Neolithic  period,  language  in,  298,  302 
Neologisms  in  deliria,  337 
in  infants,  301 
in  mania,  680 
in  paranoia,  589 

Nerve-cells,  alterations  of,  in  acufc 
delirium,  757 
in  alcoholic  insanity,  772 
in  melancholia,  695 
in  phrenasthenia,  460,  461 
in  progressive  paralysis,  812, 

814 

in  saturnine  insanity,  782 
in  secondary  dementia,  786 
in  senile  dementia,  846 
in  traumatic  dementia,  875 
canaliculi  of,  95 
mitral,  33 
number  of,  1 1 
structure  of,  91 
Nerve-centres,  acoustic,  45 
olfactory,  32 
optic,  38,  1 01 
of  bladder,  124 
of  circulation,  122 
of  common  sensibility,  48 

in  relation  to  those  of 
motility,  hearing,  sight, 
and  smell,  57,  58 


Nerve-centres  of  defsecation  and  micturi- 
tion, and  of  movements  ol  vagina, 
124 

of  different  kinds  of  sensibility,  58 
secretions,  124 
of  language,  126 

of  mastication,  deglutition,  and 
intestinal  movements,  123  I 

of  motion,  59,  109 
of  painful  sensation,  350 
of  reading,  140,  153 
of  respiration,  121 
of  writing,  144,  158,  160 
Nerve-paths,  acoustic,  45 
associative,  70 
of  common  sensation,  48 
of  motion,  59 

of  painful  sensation,  349,  350 
olfactory,  32 
optic,  38 

Nervous  system.  See  Cerebrum,  Medulla, 
and  Sympathetic  system 
and  mind,  relation  between.  9 
disturbances  of,  in  epilepsy,  521 
examination  of,  in  the  insane, 
407 

office  and  nature  of,  5,  6,  176, 
177 

organic  diseases  of,  in  phrenas- 
thenia, 454,  458 
phylogenetic  evolution  of,  6,  7,  S 
Neurasthenia,  aetiology  of,  656 
anger  in,  378 
anguish  in,  374 
attention  in,  233 

clinical  forms  and  symptomatology  • 
of,  647 

definition  of,  646 

deliria  in,  335,  336  . 

differences  between  melancholia  and,  , 

648,  695,  747 

ideation  in,  317,  320 
in  traumatic  dementia,  874 
memory  in,  277  . 

mental  confusion  in,  339 
partial,  652 

pathological  anatomy  of,  655 
prognosis  of,  658 
relations  to  delinquency,  648 
to  hysteria,  659 
to  obsessions,  649 
to  progressive  paralysis  and  , 
tabes  dorsalis,  655 
sadness  in,  372 
treatment  of,  658 

Neurasthenic  insanity,  747  ^ 

Neuro-fibrillfe,  89,  90 
Neuroglia,  function  of,  96 
histology  of,  95 
in  gray  matter,  97 
proliferation  of,  97 
relations  to  vessels  and  nervous 
tissue,  96 

Neuroglial  alterations  in  acute  delirium. 


senile,  846 
traumatic,  875 
in  epilepsy,  527 
in  pellagra.  762 
in  progressive  paralysis,  8 1 1 
in  saturnine  insanity,  783 


INDEX  OF  SUBJECTS 


899 


Neurone,  doctrine  of  the,  87,  315,  563 
NeuropiJe,  86,  90 
f Nictitropic  phenomena,  5 
Nissl’s  bodies,  91,  786 
' Nitrate  of  silver  in  epilepsy,  531 
; Noctilucus  miliar,  muscular  tissue  in,  6 
j Nominalism  and  conceptualism,  294,  864 
Nose,  anomalies  of  the,  409,  456,  457, 
466,  505 

Nymphomania,  384,  561 
' Nystagmus  in  progressive  paralysis,  804 


I O 

|l 

I Obsessions.  See  Phobias  and  h'ixcd 
i'  ideas 

; fearful,  374 

I mechanism  of,  364 

: relations  to  neurasthenia,  649 

I and  sexual  perversions,  665 

I'  Ocular  spots  in  lower  animals,  12 
I Oikophobia,  374 
I Olfactory  centres  and  paths,  32 

Onanism,  334,  414,  486,  308,  309,  363, 
::  566,  586,  656,  638,  662,  665,  696, 

: 741 

!!  Oneiric  delirium,  336 
f Onomatomania,  636 

^ Ontogenesis  in  evolution  of  language, 

i . 303 

i in  regard  to  mind  and  nervous 

j system,  9 

I of  sexual  instinct,  660 

: Opiates  in  melancholia,  698 

Optic  centre  and  visual  centre,  relation 
between,  45 

nerve,  structure  and  course,  39,  40 
Orthognatism.  See  Face 
Oxycephaly.  Sec  Cranium,  anomalies 
of 

' P 

Pain,  anatomical  seat  of,  350,  352  {note) 
and  sensation,  hypothesis  on  rela- 
tions between,  348 

j evolution  of  sensation  of,  343,  344 

' genesis  of,  350 

in  relation  to  attention,  346 
in  delinquents,  484 
in  melancholiacs.  See  Melancholia 
influence  of,  on  duration  of  associa- 
tions and  thought,  316,  317 
nature  and  essence  of,  345,  346 
relations  to  fear,  367 

to  state  of  respiration  and  cir- 
culation, 350 

Paleolithic  period,  language  in,  298,  302 
Palingnostic  delirium,  338 
Pancreas.  See  Secretions 
Panophobia,  626,  627,  689 
Paralogia,  340,  389 

Paralysis  of  muscles  in  progressive 
paralysis,  803,  807 
progressive,  aetiology  of,  817 
and  prostitution,  823 
course  of,  827 
definition  of,  788 
diagnosis  of,  825 
differential  diagnosis  from 
epilepsy,  529 


Paralysis,  progressive,  ideations  in,  317 
morbid  gaiety  in,  380 
pathological  anatom)^  of,  809, 
810 

physiognomy  in,  360 
pride  in,  381 
prognosis  of,  829 
relations  to  syphilis,  810,  816, 
821,  824,  825,  835 
to  mania,  674,  681 
to  melancholia,  696 
to  neurasthenia,  63  3 
to  pellagra.  762 
to  saturnine  insanitv,  781, 
782 

to  sensory  insanity,  735, 736 
sentiment  of  love  in,  384 
symptomatology  and  clinical 
forms  of,  788 
treatment  of,  829 
Paramnesia,  278,  338 
Paranoia,  attention  in,  237 
conception  of,  570 
course  of,  618 
diagnosis  of,  617 

different  clinical  forms  of,  372,  574, 

575.  577 

emotive  origin  of  deliria  in,  377, 

570. 

evolution  of,  577 

importance  of  altered  affectivity  in 
genesis  of,  419,  570 
in  the  various  countries,  573 
in  the  various  historical  epochs,  373 
mimicry  in,  hallucinatory,  360 
morbid  gaiety  in,  380 
paranoic  character,  574,  577,  583, 
618 

pathological  anatomy,  619 
pride  in,  381 

relations  to  alcoholism,  763 
to  other  psychoses,  376 
with  epilepsy,  503,  509,  510, 

514.  5^5 

religious  mania  in,  382 
sentiment  of  family  in,  383 
of  love  in,  384 
therapy,  619 
acute,  713,  736,  737,  742 
climacteric,  470 
hypochondriacal,  733,  734 
hysterical,  559,  560 
late,  743 

neurasthenic,  648 
of  middle  age,  470 
pubescent,  470 
rudimentary,  641,  642 
secondary,  576,  692,  730,  784 
Paraphrasia,  340,  341 
Paraphrenia,  470 
Parathyroid.  See  Thyroid 
Passional  ])oses  in  hysteria,  557,  566 
Pathophobia,  629 
Pederasty,  664,  668 
Pediophobia,  629 

Pellagra.  See  Insanity,  pellagrous 
Perception  and  apperception,  difference 
between,  180 

and  attention,  relations  between, 
224 

and  memory,  relations  between,  243 
and  reaction  relations  between,  197 


rjoo  INDEX  Of  SUBJECTS 


Perception  and  sensation,  difference 
between,  177 

and  sensation  in  relation  to  param- 
nesia, 2jS 

anomalies  of,  in  the  various  mental 
affections,  194 

as  a foundation  of  intelligence,  197 
compensatory  perceptive  hyper^ 
functionality,  195 
conception  of,  106 
examination  of,  in  insane,  402 
factors  of,  178 
in  chorea,  751 
in  delinquents,  491 
in  dementia,  post-apoplectic,  85(3, 

851 

in  dementia,  secondary,  783 
in  epilepsy,  510 
in  hysteria,  539,  555 
in  mania,  677 

in  phrenastheniacs,  431,  432 
in  progressive  paralysis,  792 
in  sensory  insanity,  721,  722 
influence  of  age  on,  183 
law  of  time  in,  191 
})henomena  of  interference  in,  182 
physiopathology  of,  176 
progressive  character  of  perceptive 
process,  179 

repetition  of  stimulus  in,  183 
sense  of  space  in,  187 
sense  of  time  in,  184 
value  and  effects  of  intensity  of 
stimulus  in,  181,  182 
visual,  observations  and  experi- 
ments upon,  178 

whether  it  exists  in  protozoans,  5 
Perceptions  and  phobias,  relations  be- 
tween, 629 

and  sentiments  as  fundamental 
factors  of  the  mind,  177 
Persecuted  persecutors,  333,  521,  587 
Persecution,  delirium  of,  331,  334,  585, 
609,  615,  690,  692,  745,  801 
Personal  history,  examination  of  in  the 
insane,  413 

Personality,  augmentation  of,  292,  324 
duplication  of,  272,  276,  279 
examination  of,  in  the  insane,  402 
in  alcoholic  insanity,  769 
in  hysteria,  534,  556,  557,  567 
in  malady  of  fixed  ideas,  620,  >621, 
622 

in  mania,  676,  677 
in  melancholia,  685,  687,  689,  691 
in  progressive  paralysis,  790,  792, 
802,  828 

in  secondary  dementia,  783,  787 
in  sensory  insanity,  705,  706,  71 1, 
712,  719,  720,  722,  725 
reconstruction  of,  in  aphasic  de- 
mentia, 866,  869 
relations  to  kinaesthesis,  343 
transformation  of,  320,  334,  335, 
339.  342,  570.  589.  691 

Perversions,  sexual,  aetiology  of,  668 

and  fixed  ideas,  relations  be- 
tween, 642 

and  sentiment  of  love,  relations 
between,  384,  385 
forms  of,  661 
in  delinquency,  486,  491 


Perversions,  sexual,  in  epilepsy,  509 
in  paraphrenia,  472 
prognosis  of,  669 
psychopathology  of,  660 
treatment  of,  669 

Pessimism  in  neurasthenia,  646,  649 
Philology,  298 

Phobias  Ideas,  fixed,  and  Obses- 

sions),  374,  &lb 

Phrenasthenia,  aetiology  of,  462 
attention  in,  236 

definition  and  general  remarks,  429 
general  symptomatology,  430 
ideation  in,  320 
memory  in,  264,  265,  280 
pathological  anatomy  of,  457 
prognosis  of,  463 
sentiment  of  love  in,  383,  384 
treatment  of,  464 
vanity  in,  380 

and  alcoholism,  relations  between, 

463.  765 

and  aphasic  dementia,  parallel  be- 
tween, 864 

and  epilepsy,  455,  458,  464 
and  delinquency,  475,  477 
and  malaria,  464 
and  paraphrenia,  470 
Phrenosis,  sensory.  See  Insanity,  sensory 
Phylogenesis  in  evolution  of  language, 
303 

in  relation  to  mind  and  nervous 
system,  9 

of  sexual  instinct,  660 
Physical  condition  in  the  insane,  exami  - 
nation  of,  410 

Physiognomy  of  the  aphasic,  857,  865 
of  the  cretin,  467 
of  the  delinquent,  483 
of  the  epileptic,  521,  522 
of  the  katatonic,  729 
of  the  paralytic,  793,  797 
Plagiocephaly,  See  Cranium,  anomalies  of 
Plagioprosopia.  See  Face 
Plastiduli,  intelligence  in,  4,  176 
Platonists,  662,  664 

Platycephaly.  See  Cranium,  anomalies 
of 

Pleasure,  anatomical  seat  of,  350,  351 
{note) 

evolution  of  sensation  of,  343,  345 
nature  and  essence  of,  345,  346 
relation  to  attention,  346 

to  state  of  circulation  and  re- 
spiration, 350 
Plethysmograph,  407 
Pneumography,  407 
Pneumonia  of  paralytics,  805,  815 
Porencephaly,  458,  526 
Positivism  and  metaphysics,  4 
Potamophobia,  629 

Poverty  in  causation  of  delinquency,  497, 

499  . . , 

Pregnancy  in  the  etiology  of  melan- 
cholia, *696 

Preperception,  202,  204,  227 

Presbyophrenia,  470 

Pressure  of  blood  in  relation  to  attention, 

233 

Pride,  analysis  of  sentiment  of,  381 
in  epileptics,  509 
in  genesis  of  paranoia,  571 


INDEX  OF  SUBJECTS 


901 


I;  Prisons  in  aetiology  of  delinquency,  498, 
I 502 

I Processomania,  614 

i Prognathism.  See  Face 

j Progress  and  evolution  of  human  mind,  i 
j Prophesy,  delirium  of,  334 
i Propositions  and  judgments,  313 
Prostitution,  496,  497,  500,  823 
j,  Protista,  intelligence  in,  4 

II  Protoplasm  and  intelligence,  4 
I Pseudo-hallucinations,  209 

I'  Pseudo-paralytics,  826,  835 
i Psychiatry,  definition  and  limits  of,  i 
j Psychopathology,  scope  of,  9 

Ptomaines  in  genesis  of  epilepsy,  523 
[ Pupils,  behaviour  of  in  acute  delirium, 

756,  759 

in  alcoholic  insanity,  770 
I in  melancholia,  736 

in  progressive  paralysis,  804, 

; 807,  814 

in  saturnine  insanity,  782 
i in  stupor,  736 

I 

: Q 

; Querulous,  the,  614,  778,  786,  841,  851 
R 

; Rachialgia  in  neurasthenia,  651 
I Rachitis,  a cause  of  epilepsy,  525 
I Raptus  in  melancholia,  275,  688,  693 
1 Reaction  and  perception,  relation  be- 
I tween,  197 

j in  delinquents,  489 

I in  epileptics,  508 

^ in  phrenastheniacs,  432 

[ law  of,  in  ideation,  318,  319 

j measure  of  time  of,  in  the  insane,  406 

j time  of,  in  mania,  676 

; modified  by  attention,  231 

‘ Reading,  cortical  centre  of,  140,  153 
Reception,  capacity  for,  176,  241 
Recognition,  delirium  of,  278,  280,  338 
power  of,  256 

Re-education  in  aphasic  dementia,  865 
of  dements,  282  {note) 

Reflexes  in  alcoholic  insanity,  770 
in  mania,  681 
in  morphinic  insanity,  776 
in  neurasthenia,  652 
in  pellagra,  761 
in  progressive  paralysis,  804 
I Regicides,  473 

Religion  and  hallucinations,  208 
Religious  delirium,  334,  559,  560,  599, 
600,  601 

sentiment  and  moral  sentiment, 
relations  between,  363 
defect  of,  in  aetiology  of  delin- 
quency, 498,  500 
in  delinquents,  489 
in  epileptics,  508,  509 
in  phrenastheniacs,  437 
psychopathology  of,  381 
I Reproduction  of  impressions,  252,  25  5 
Respiration,  cortical  centres  of,  1 21,  122 
in  epilepsy,  disturbances  of,  518 
modification  of,  during  attention,  233 
relations  to  states  of  pleasure  and 

pain,  350.  359 


Retentiveness  of  impressions,  240 
measurement  of,  406 
Retina  and  chromatic  sense,  181 

projection  of  upon  cerebral  cortex, 
43 

structure  of,  38 
Revivification,  256 

Revulsives  in  progressive  paralysis, 
831 

Rhythm,  doctrine  of,  185 

importance  of,  iu  notion  of  time, 
183 

Rupophobia,  628 


S 

Sadism,  666,  669 

Sadness,  365,  372 

Salicylate  of  soda  in  epilepsy,  531 

Saliva.  See  Secretions 

Satyriasis,  384 

Scaphocephaly.  See  Cranium,  anomalies 
of 

Schools  in  causation  of  delinquency,  499 
of  neurasthenia,  656 
Secretions,  cortical  centres  for  the 
various,  1 24 

in  states  of  pain,  modification  of, 

352,  358 

Senility.  See  Dementia,  senile 
Sensation  and  perception,  difference 
between,  177 

in  relation  to  paramnesia,  278 
definition  of,  177 
evolution  of,  177 
in  phrenasthenia,  43 1 
in  relation  to  emotion  and  intellect, 
343 

Sense,  chromatic,  {see  Daltonism)  evolu- 
tion of,  181,  303 
in  phrenasthenia,  43 1 
in  progressive  paralysis,  804 
muscular,  function  of,  in  sense  of 
space,  187,  188,  189,  204 
importance  of,  in  memory,  421, 
242 

of  space,  187 
of  time,  1 84 

Sensibility,  disturbances  of,  in  progres- 
sive paralysis,  803 
in  delinquents,  484 
in  epileptics,  522 
common,  centres  and  paths  of,  48 
importance  and  function  of 
centres  of,  in  language,  126 
et  seq. 

in  sense  of  space,  187 
relation  between  nerve-centres 
of,  and  those  of  hearing, 
motility,  sight,  and  smell, 
57>  58 

Sentiment,  moral,  evolution  of,  166,  362, 
363 

in  alcoholists,  768,  770 
in  apoplectic  subjects,  851 
in  delinquents,  475,  486 
in  hysterical  subjects,  556 
in  insanity  in  general,  385 
in  maniacs,  676 
in  paraphreniacs,  472 
in  phrenastheniacs,  437,  43S 


902 


INDEX  OF  SUBJECTS 


Sentiment,  moral,  in  progressive  para- 
lytics, 790,  791 
organizations  of,  385 
relations  to  religions  sentiment, 
363 

of  family,  166,  382 
religious.  See  Religion 
Sentiments.  See  Emotions 

anatomical  seat  of,  166,  350 
and  perceptions  the  two  funda- 
mental data  in  mind,  177 
evolution  of,  345,  361 
examination  of,  in  the  insane,  404 
in  alcoholists,  768 
in  choreic  subjects,  751 
in  hemiplegic  individuals,  850 
in  melancholiacs,  687,  692 
in  phrenastheniacs,  437 
physio-pathology  of,  343 
relations  to  kinaesthesis,  344,  345 
Serum-therapy  in  epilepsy,  525 

in  progressive  paralysis,  832 
Siderophobia,  374 

Sight.  See  Daltonism  and  Chromatic 
sense 

centre  and  paths  of  sense  of,  38, 
100 

disturbances  of,  in  progressive  para- 
lysis, 804 

evolution  of  organ  of,  12,  13 
experiments  and  observations  upon 
visual  perceptions,  178 
function  of,  in  sense  of  space,  187 
and  importance  of,  in  language, 
126  et  seq. 
in  delinquents,  484 
organ  of,  in  inferior  animals,  12,  13 
Simulation  in  hysterical  subjects,  538 
in  female  delinquents,  497 
in  male  delinquents,  491 
Skin,  alteration  of,  in  pellagra,  760,  762 
Sleep,  hypotheses  on  the  cause  of,  314 
in  acute  paranoia,  742 
in  dementia,  luetic,  834 
priccox,  725 
senile,  841 

in  epilepsy,  ^13,  314,  316 
in  hysteria,  558 

in  mania,  prodromal  period,  677, 
680 

in  melancholia,  688 
in  neurasthenia,  650 
in  paranoia,  586 

in  progressive  paralysis,  791,  801 
in  saturnine  insanity,  781 
thought  during,  213 
Smell,  centres  and  paths  of,  32 

function  of,  in  the  sense  of  space, 
189 

in  delinquents,  484 
in  phrenastheniacs,  432 
Social  surroundings  of  the  insane.  See 
Environment 

Soma-'sthetic  zone,  relation  to  sensations 
of  pleasure  and  pain.  350 
Somnambulism  in  hysteria,  557 
in  epilepsy,  507,  517 
Sounds,  limits  of  perception  of,  according 
to  age,  183 
localization  of,  188 
Space,  anal^^is  of  sense  of,  187 
pathology  of  sense  of,  628 


Speech  {see  I.anguage),  disturbances  of, 
in  epilepsy,  522 
in  progressive  paralysis,  793, 
826,  827 

in  saturnine  insanity,  782 
in  cretins,  467 

regression  of,  in  phrenastheniacs,  443 
Sperm,  disease  of,  661,  669 
in  phrenastheniacs,  464 
Stammering,  793 

Statistics  of  hallucinated  persons,  207 
on  aetiology  of  phrenasthenia,  463 
' on  cases  of  mania,  675 

on  mortality  in  pellagra,  763 
on  recoveries  from  hysteria,  568 
i from  melancholia,  697 

j on  relations  between  alcoholism  and 
I delinquency,  768 

I syphilis  and  other  causes 

! in  progressive  paralysis, 

817 

on  syphilitic  insanity,  753 
on  termination  of  sensory  insanity, 
737 

on  traumatic  psychoses,  876 
Stature.  See  Dwarfism  and  Giantism 
examination  of,  in  the  insane,  409 
in  cretins,  467 
in  delinquents,  483 
I in  myxoedematous  idiots,  45  5 

1 Stenocrotaphy.  See  Cranium,  anomalies 
of 

Stigmata  of  degeneration,  examination 
of,  in  the  insane,  408 
in  born  criminals,  477,  483 
in  delinquents  from  habit,  501 
in  epileptics,  505,  521 
in  female  criminals,  497 
in  phrenastheniacs,  444,  455, 

456,  457.  466,  467 

in  sexual  perverts,  664 
Stimulants  in  aetiology  of  neurasthenia, 
656 

influence  of,  on  memory,  263 
Stimuli,  indifferent,  346 

of  distraction,  231,  232 
Stimulus,  intensity  of,  in  genesis  of  pain, 
349 

in  perception,  181 
repetition  of,  in  perception,  183 
what  is  meant  by  the  term,  177 
Stupidity,  neurasthenical,  649 
Stupor.  See  Confusion,  mental,  and 
Insanity,  sensory 
in  katatonia,  729 
in  saturnine  insanity,  781 
in  traumatic  dementia,  872,  873 
post-epileptic,  514 

j relations  to  melancholia,  693.  697 
Stylonichia  mytilns,  nervous  tissue  in,  6 
Suggestion  as  source  of  illusions,  203 
in  treatment  of  hysteria,  569 
j of  obsessions,  644 

I of  sexual  perversions,  669 

j Suggestivity  in  hysterical  subjects,  540 
! in  katatonic  subjects,  728,  729 
in  phrenastheniacs,  442 
Suicide  from  psychic  contrast,  310 
ideas  of,  in  ereutophobia,  375 

in  persecutory  paranoia,  587 
in  alcoholic  insanity,  tendency  to, 
767 


INDkX  OF  SUBJECTS 


Suicide  in  delirium  of  negation,  330 
in  epilepsy,  513,  514 
in  hysterical  melancholia,  559 
in  melancholia,  688,  694,  698 
in  morphinism,  776 
in  neurasthenia,  tendency  to,  61.7, 
650,  658 

in  obsessions  in  general,  643 
in  obsessive  impulses,  634  > 

in  progressive  paralysis,  796,  800 
in  saturnine  insanity,  781 
in  secondary  dementia,  783 
Sympathetic  system,  alterations  of,  in 
pellagra,  762 

Syphilis,  relations  to  epilepsy,  523,  525, 
754.  836,  837 
to  hysteria,  837 
to  neurasthenia,  657 
to  progressive  paralysis,  810 
Syphilitic  dementia.  See  Dementia,  luetic 

833 

insanity,  753 


T 

Tachycardia  in  epilepsy,  518 
in  neurasthenia,  647,  653 
Tactile  zone,  relations  to  sensations  of 
pleasure  and  pain,  350 
Taphophobia,  375 
Taste  in  delinquency,  484 
in  phrenastheniacs,  432 
Tattooing,  484 
Tears.  See  Secretions 
Teeth,  anomalies  of  the,  410,  456,  467, 

48  3 

Temperature,  cortical  centre  of,  125 
in  acute  delirium,  7ce,  736’  71:0 
paranoia,  743  ’ 

in  alcoholic  insanity,  766,  772 
in  chorea,  752 
in  melancholia,  693 
in  myxoedematous  idiocy,  456 
in  pellagra,  761 
in  post-epileptic  insanity,  514 
in  progressive  paralysis,  'Soi,  806 
807,  808 

in  saturnine  insanity,  781 
in  sensory  insanity,’ 72 1 , 737 
Tendencies,  inquiry  into,  in  history  of 
insane,  413 

Tnought.  See  Ideation  and  Intelligence 
anatomical  seat  of,  313 
and  brain,  relation  between,  4 {note) 
and  emotion,  relation  between  ^10 
570  ’ ’ 

and  language,  relation  between 
863,  864  ' 

anomalies  of,  315 
during  sleep,  213 
ev^olution  of,  297 
law  of  time  in,  316 
progressiveness  of,  295 
Tnymus,  alterations  of,  in  epilepsy, 

I nyroid,  alterations  of,  in  cretinism  466 
4^7.  468 

in  myxoedema,  456 

Tics  and  epilepsy,  relation  between 

. 503 

in  phrenastheniacs,  439 


( Time  in  association  of  ideas,  308 
law  of,  in  perception,  191 
in  thought,  316 

of  reaction  in  the  insane,  measure- 
ment of.  406 

modified  by  attention,  231 
sense  of,  184 
'Fimidity,  372,  630 

Topoalgias  in  neurastheniacs,  6c  i,  653 
1 oxines  in  genesis  of  epilepsy,  323 
traumata.  See  Demeatia,  traumatic 
and  tumours,  relation  between,  876 
in  letiology  of  epilepsy,  523,  525 

874 

of  hysteria,  566,  873 
of  neurasthenia,  657,  874 
Trenaors  in  progressive  paralysis,  802 
in  senile  dementia,  843 
Trephining  cranium  in  progressive  para- 
lysis, 832 

in  traumatic  dementia,  877 
Trigonocephaly.  See  Cranium,  anoma- 
lies of  r — 

Trunk,  anomalies  of  the,  410,  456,  457, 
467 

Tumours  of  brain,  a cause  of  epileps\q 
505 

and  traumata,  relation  between 
876 

slowness  of  thought  arising 
from,  317 

Tumultus  sermonis,  316,  340 


U 

Ultrabrachycephaly.  See  Cranium,  ano- 
malies of 

Jltradolicocephaly.  See  Cranium,  ano- 
malies of 

Unconscious,  the.  See  Consciousness 
in  fixed  ideas,  621 
in  genesis  of  deliria,  321 
in  hysteria,  540,  556 
in  paranoia,  ’586,  601 
relations  to  consciousness,  397 

Urine  in  acute  delirium,  7^7 

in  diagnosis  of  morphinism,  776 
in  melancholia,  694 
in  paralytics,  8o5,  807,  809,  820 
m saturnine  insanity,  781 
in  senile  dementia,  844 
toxicity  of,  in  epileptics,  523,  524 
in  the  insane,  670,  671 

Uxoricide  in  paranoia,  590 


V 

Vagina,  cortical  centres  for  movements 
of,  124 

Vanity,  analysis  of  sentiment  of,  380 
in  delinquents,  488 
in  eccentric  individuals,  472,  473 
in  epileptics,  509 
in  genesis  of  paranoia,  571 
in  hysterical  subjects,  538 
in  phrenastheniacs,  436 

Veneration,  sentiment  of,  in  epileptics 

508  11. 

\ ertebrates,  nervous  system  of,  8 


INDEX  OF  SUBJECTS 


904 


Vertigo  in  neurasthenia,  650 
in  pellagra,  760 

in  )X)st-apoplectic  dementia,  849, 
850 

in  traumatic  dementia,  875 
Visual  field  and  attention,  232 
in  anger,  369 
in  delinquency,  484 
in  progressive  paralysis,  804 
Volitional  movement,  factors  of,  113 
Voracity  in  idiots,  432 
in  paralytics,  803 


W 

Water,  influence  of,  in  cretinism,  468, 

469 

Word-blindness.  See  Dem.entia,  aphasic, 
286,  522 

Word-deafness.  See  Dementia,  aphasic, 
157.  197.  285,  522 


Will  and  memory,  252 
freedom  of,  388,  389 
in  mania,  678 
in  obsessions,  624 
physio-pathology,  of  386 
relations  to  attention,  224 
Writing,  cortical  centre  of,  144,  158, 
160 

examination  of,  in  insane,  407 
in  mania,  680 

in  progressive  paralysis,  791,  795, 
802 


Z 

Zincomania,  631 

Zone,  somaesthetic,  relations  to  sensa- 
tions of  pleasure  and  pain,  350 
tactile,  relations  to  sensations  of 
pleasure  and  pain,  350 
Zones,  associative,  149 

of  evolution,  143,  152,  158,  288 


THE  END 


/iamierc,  Tind<xll  and  Cox,  8,  Henrietta  Street,  C event  Carden,  London 


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